Independence PD Timothy Loehmann Records
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Transcript of Independence PD Timothy Loehmann Records
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T
a f t
2
00 u b l i c
Square,
u i t e 3500 / C
leveland,
Oh
io
44114-2
T e l :
216.2
41.2838
/
F
a x :
21 6
.241.3
wwvv.ta
ftlaw.
GR GORY . O
RIEN
2 1 6 - 7 0 6
- 3 8 7 0
g
o b r i e n @ t a f t l
a w . c o m
Dece
mber
3,
2014
Via
-
M a i l
Ed
G a l l e k
EG
allek a
moio.com
)
C
ory
S
h a f f e r
CSha
ffea.cl
eveland
.com)
Pe
ggy
S i n k
o v i c h
Pe
cw.Sink
ov ich@f
oxacorn
)
J
e n n i f e r S
mola
JSmol
aap.or
g)
Andrew
T
obias
an
drewito
bias@qm
ail.com)
Re:
O. R. C.
149.43
P u b l i c
RecordsRequest
Ti
mothy L
oehman
n
L
adies/Ge
ntlemen
:
Attac
hed plea
se
i n d reco
rdsresp
onsive
t o your
p u b l i
c
recor
ds
reques
t o the
C i t y
of
I
ndepend
ence
Bates
Numb
ered
I
ND00000
1 t
hrough I
ND00006
1).
f
you ha
ve a l s o req
uested
t o
r e
v i e w the
o r i g i n a l
p u b
l i c r e c o r d
s ,
ple
ase
coor
dinate
a
tim
e w i t h
Kathy
A
l e x i e 216) 52
4-4131
who l l
mak
e
t
he
o r
i g i n a l rec
ord s
e x c l u d i
n g
exe
mpted
i n f o r m
a t i o n a
v a i l a b l e f
o r
i n s
p e c t i o n
d u r
i n g
th
e normal
bus
iness
hours
of
t h e C i t y
Th
e
record
s p r o v i d e
d f u
l l y respo
nd t o
y
our r e
q u e s t .
Pl e
ase
c o
n t a c t me
hou
ld
y
ou
ha ve
any
u r t h e r
q u e s t i
o n s .
I n
t
he
me
antime, th
e C i t
y
does
n o t
w
aive an y
a n d
exem
p tions
o r
d
efenses
a f
f o r d e d
t o
t
pursua
nt o R.C
.
149
.43
t
se
q.o r
Ohiolaw
r e l
a t i v e
t o non -
p r o d u c t i
o n .
Thank you.
S i
n c e r e l y ,
f
111
41111
1PO4
Grego
Law
D i r
t o
Atta
chment
c c :
G
regory P.
K u r t z
, May
or
K
athy A l e x i e
,
R
ecords
Cust
odian
O f
f i c e r
T a f t S t e t t i n i u s
o l l i s t e r
LLP
Chicago
C i n c i n n a t i
/
Cleveland
/
Columbu s
/
Da yton /
n d i a n a p o l i s
/
Nort hern Kentucky
/
Phoe
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P . 1
*
C o m m u n i c a t i o n
R e s u l t
R e p o r t
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ndependence
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IND 2
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7/25/2019 Independence PD Timothy Loehmann Records
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7/25/2019 Independence PD Timothy Loehmann Records
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I f you e l e c t t o
c o n t i n u e coverage
w i t h i n
t h e
e l e c t i o n p e r i o d
but
a f t e r coverage
has
e r m i n a t e d ,
coverage
w i l l be r e i n s t a t e d
r e t r o a c t i v e l y t o
t h e
date
t t e r m i n a t e d (December
31,
2012).
f
you
waive
c o n t i n u a t i o n coverage,
you
may
evoke
your
w a i v e r
a t
any
t i m e b e f o r e February
15,
2013;
however,
your c o n t i n u a t i o n
coverage w i l l b e g i n on
the date
your
w a i v e r
i s
r e v o k e d .
Coverage w i l l n o t
i n c l u d e the
p e r i o d between
the
date
your
r e g u l a r
p l a n coverage
t e r m i n a t e d
and t h e
date
the
w a i v e r
i s
revoked.
I f
you
do
not
l e c t any
coverage
by
February 15,
2013,
you
may
ot
do
so
a t e r .
I f you
e l e c t
c o n t i n u a t i o n
coverage,
you do not have
t o
send any
payment
w i t h your
e l e c t i o n
form.
However , you
must
make
our
i r s t
payment no
a t e r
than 45 ays
a f t e r
the
date
of your
e l e c t i o n .
I f
you
do ot
pay the
f u l l
premium
amount
i t h i n 45 ays
a f t e r
your
election
date,
you w i l l lose a l l continuation coverage
r i g h t s
and
your
coverage
w i l l
;automatically e f r m i n a t e .
Thereafter,
pr emium payments for
coverage are due
i n
advance and
payable
on
the
f i r s t
of each preceding
month.
Once
again,
f
you do
not
pay
the
u l l
premium
amount
on
the
f i r s t of the preceding month,
you
may
lose
a l l
c o n t i n u a t i o n
coverage
r i g h t s
and
your
coverage
may
u t o m a t i c a l l y t e r m i n a t e .
Please
make
your check payable
to
the
City
of Independence
Group
Health
Plan.
Remember h a t your
payment
s s u b j e c t t o chang e as
h e
cost
of
h e
p l a n ' s
coverage
f o r
the
C i t y o f
Independence
does change.
I f you
o r
a
covered
f a m i l y member s
determined
t o have
been d i s a b l e d
(under
i t l e s
I I
of
XVI
of
t h e S o c i a l S e c u r i t y
Act)
as of
December
31,
2012,
t h a t person
may
be
e n t i t l e d t o a
o t a l
o f
29
months
of
c o n t i n u a t i o n
coverage
i n s t e a d of 18
onths). To
e c e i v e
t h i s extended
coverage
p e r i o d ,
the
C i t y
must be n o t i f i e d d u r i n g t h e i n i t i a l 1 8
-month coverage
p e r i o d
and w i t h i n 60
ays
o f r e c e i v i n g S o c i a l
S e c u r i t y ' s
d e t e r m i n a t i o n . A
i g h e r
premium i s r e q u i r e d
f o r
the
1 9
t h
through
29
h
months of
o n t i n u a t i o n coverage
g e n e r a l l y
150
p e r c e n t
of
the
u l l monthly
premium. This
extended
coverage may
nd
because o f any of
the
reasons l i s t e d
above
(except h a t
the
i r s t
s c e n a r i o i s extended
t o
the end of your 29
-month
coverage p e r i o d )
o r
because
S o c i a l
S e c u r i t y
determines
h e
person i s no l o n g e r d i s a b l e d . I n
the
a t t e r
case,
extended
coverage ends
on
the
f i r s t day of h e month t h a t
begins
more than 30 ays
f t e r
t h e
date
of h a t
d e t e r m i n a t i o n .
I f
you
have
any
q u e s t i o n s , please
do
n o t h e s i t a t e t o
c o n t a c t me t
216/447-1100.
Please
complete and r e t u r n the enclosed e l e c t i o n
form
by February
15,
2013,
f
you decide
o
c o n t i n u e
coverage.
S i n c e r e l y ,
osep
D'
Lubin
ector
IND 4
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C
ITY
OF
INDE
PEN
DENC
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v e D
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umn)
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4
CKN
OWLE
DGEM
ENT
OF
PER
SONRE
CEIV
ING
TH
IS NO
TICE:
have
read
and
understand
t h i s
n o t i c e ,
and
am
aware
o f
my
i g h t s
concerning
my
p t i o n
t o
continue
cover
u
nder the p l a n ( s )
s
p e c i f i e
d
h
e r e i n .
By
s i g
n i n g
t h i
s
form,
the
d e c i s i
o n
make
w i
t h
r
e g a r d
t o an y
p
l a n
f o r
whi
declin
e
covera
ge
m
aybe
revoke
d
b e f o
r e
Februa
ry
15.
201
3.
I f
r
evoke
any
wa iv
er o f
c
overag
e
un
der a
be f
ore
t h a t
d a
t e ,
under
stand
t h
a t
my
o n t i n u a
t i o n
co
verage
unde
r
t h
a t
p
l a n w l l
b e g i n
on
the
d
ate
revo
ke
wai
ver.
f
d
o
not
l
e c t
t o
c
ontinu
ecov
erage
b
e f o r e
Febru
ary
15,
2
013,
e l i g i b i l i
t y
f o r
c o n t i n
u a t i o n
cov
erage
un
the
abo
ve p
l a n ( s )
l
l end.
ackn
owledg
e t h a t ha
ve read
and
unde
rstand
t
h i s n o t i
c e , and
am
awar
eo f
m
y
i g h
t s con c
ern ing
m
y
p
t i o
cont
inue
cover
ag e
u
nder
th
e
plans
s p
e c i f i e d
h e r e i
n . unde r
st and
t
h a t the cost
o f
the
c
overag
e i s
s
u b j e c
chang
e
dep
ending
on t
he
pr
emi u m
s ch
arged
by
the
c a r r
i e r ( s )
and t h a t
r a t e s are
guara
nteed
th
rough
De
cem
31,
201
3
n l
y . L a s t l y ,
un
dersta
nd
t h
a t
i f e l e c t c o n
t i n u a t i
o n
co
verage
,
do n
ot
have t o s
end
any
paymen
t
my
l e c t i o n
form.
Howe
ver,
agre
e
t o
make myi r s t
pay
mentno
a t e r tha n 4
5
ays f t e r
the date
of my
l e c
t
I
f don o
t pay th
e u l l
p
remium
amoun
t w i
t h i n
45
ays a f t e r
my
l e c t i o n
d a t e , un
dersta
nd
t h a
t
w
i l l l o
s e
c o n t
i n u a t i
o n cov
erage r i g h t
s
a
nd my
ove
rage
i l
l
a u
t o m a t i c
a l l y t e r m i n
a t e .
Therea
fter,
prem
ium
p
aymen
t
for cov
erage
i
s due
i n
adv
ance
and payab
le
on
the
1 s
t
o
f
eac
h
prece d
mo
nth.
M
akeyour
ch
eck p
ayable
to th
e C i t y o f
Indepe
ndence
Grou p
He
alth
Plan
.
Si
gnatur
e
Dat
e
P
lease
return
this
formto t
he
City o
f
I
ndepe
ndenc
e
6800
Bre
cksvil
le
Roa
d,
nd
epende
nce,
O
H
4131
)
wh
ether
or no
t
yo
u a
re
ele
ctingC
OBRA
over
age.
IND 5
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L e
t t e
r
R e s
i g n
a t
i o n
T
o:
C
hie
f
o
la
k
Fr
om
:
Ti
mo
th
y
Lo
e h
ma n
n
Da
te
:
D
ec
em
be
r 5
,
20
12
P l
e a
s e
a
c c
e p t
t h
i s l e t
t e r
a s
my
f f
i c i
a l
r
e s i
g n a
t i o
n
a
s a
p
atr
ol
ma n
o r
t h
e C i t
y
o
f
I
nd e
pe
nd e
nc
e.I
a
m
e s i
g n
i n g
my
omm
is
si
on
o r
p
e r s
o n
a l r e
a s
o n s
a t t h
i s
t i
m e
.
T
ha
nk
yo
u
o
r t h
e
o
p p
o r t
u n i
t y
and
r a
i n i
n g
I ha
ve
e c
e i v
e d
.
T
imo
th
y
L
oe
S
g t
. Gr
eg
r e l
i c t
39
45
=
7
;
07
1/
57
11
1/
2
6
a
IND 6
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SGT.
OEL
BARRON
Training
Division
EUCLID
POLICE
DEPARTMENT
\ -
545
East
222nd
t r e e t
E u c l i d ,
Ohio
44123
D i r e c t :
216.289.8465
Fax:
216.289.8543
e m a i l :
IND 7
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AUTHORIZATION
TO ELEASE NFORMATION
TO
WHOM
T MAY
ONCERN:
I h e r e b y
a u t h o r i z e
any
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of
u c l i d b e a r i n g
t h i s r e l e a s e
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copy h e r e o f ,
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myemployment,
r e d i t ,
o r
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r e c o r d s ,
n c l u d i n g b u t not
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t t e n d a n c e ,
a t h l e t i c ,
p e r s o n a l
h i s t o r y
and
i s c i p l i n a r y r e c o r d s ,
m i l i t a r y
r e c o r d s ,
m e d i c a l
r e c o r d s
and c r e d i t r e c o r d s ,
i n c l u d i n g
t h e Ohio
Bureau
of orkers'
ompensation.
h e r e b y
d i r e c t you
t o
r e l e a s e
s u c h i n f o r m a t i o n
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waive
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agreements
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o n f i d e n t i a l i t y
r e g a r d i n g
any
e q u e s t e d
i n f o r m a t i o n .
1
h e r e b y
a u t h o r i z e and
i r e c t
t h e r e l e a s e
and
i s c l o s u r e t o any u l y a u t h o r i z e d a g e n t ,
o f f i c e r
o r
employee
of
h e C i t y
of
u c l i d ;
of
Consumer
Report as
h a t
tern
s
d e f i n e d
i n
t h e
F a i r
C r e d i t
R e p o r t i n g
A c t , 15
U.S.C.
681a d) nd
h a l l
be
deemed
f f e c t i v e
t o
p e r m i t
t h e r e l e a s e
a n d / o r
u s e
of
Consumer
Report
f o r any
u r p o s e
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h e
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C r e d i t R e p o r t i n g A c t ,
1 5
U.S.C. 1631 e t
s e e . .
I
e r e b y a u t h o r i z e
and
acknowledge h e C i t y
of
u c l i d ' s
u s e
of
a i d
Consumer` epott o r
employment
u r p o s e s .
I
e r e b y
r e l e a s e
you,
s
t h e
c u s t o d i a n
of
uch
r e c o r d ,
and
any
c h o o l ,
o l l e g e ,
u n i v e r s i t y ,
or
t h e r
e d u c a t i o n
i n s t i t u t i o n , : h o s p i t a l
o r
o t h e r
r e p o s i t o r y i f
medical
e c o r d s , m i l i t a r y
r e c o r d s , c r e d i t
b u r e a u ,
l e n d i n g i n s t i t u t i o n s ,
consumer
e p o r t i n g agency, o l i c e
d e p a r t m e n t s
o r
e t a i l
b u s i n e s s
e s t a b l i s h m e n t s ,
i n c l u d i n g
i t s
o f f i c e r s ,
employees, r r e l a t e d
p e r s o n n e l ,
b o t h
i n d i v i d u a l l y and o l l e c t i v e l y , from
any
and
l l
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f o r damage r
whatever
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i m e r e s u l t t o
me, my
e i r s , a m i l y
o r
a s s o c i a t e s
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ompliance w i t h
t h i s
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and
r e q u e s t
t o
r e l e a s e i n f o r m a t i o n ,
o r
any
t t e m p t
t o
comply
i t h i t .
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t o
t h e
v a l i d i t y of
h i s
r e l e a s e , p l e a s e
c o n t a c t
t h o
C i t y
of
E u c l i d
Human
Resource
Department.
T h i s
r e q u e s t i s
e x e c u t e d
w i t h
f u l l
knowledge
and
u n d e r s t a n d i n g
t h a t
t h e
i n f o r m a t i o n
i s f o r o f f i c i a l u s e
of
t h e C i t y
of
u c l i d . Consent s
g r a n t e d
f o r
t h e
C i t y
of
u c l i d
t o
f u r n i s h
s u c h
i n f o r m a t i o n a s
d e s c r i b e d
above
o
t h i r d
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t h e
c o u r s e
of
u l f i l l i n g i t s o f f i c i a l
r e s p o n s i b i l i t i e s .
S i m i l a r l y , where p p l i c a b l e ,
t h i s
R e l e a s e
s h a l l
be
deemed
w r i t t e n
c o n s e n t
f o r
d i s c l o s u r e of
e c o r d s
p u r s u a n t t o
5 . U . S : C . A .
552a b)
(West
2013).
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IND 9
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Memb
er
Deta
il
Repo
rt
USTO
MER/GR
OUP
INF
ORMATI
ON:
us
tomer/Gr
oup:
Cit
y
of
Indepe
ndence 0743697
)
m
ployee:
TIMOTHY
A
LOEHMA
NN
ate ID:
MBER
INFOR
MATION
:
ember
N
ame:
TIMOT
HY A
L
OEHMANN
:
:
ip:
tionship
: EE
EMP
LOYEE
rtabilit
y Appli
es:
dress
Start
Date:
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/2012
n
al Effec
tive Da
te:
07/11/2
012
st UpdateD
ate:
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/25/2012
Home
Ph
one:
rk Phone:
1111111
11111111
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City: ate:
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Foreign
dr
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Preferre
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ent:
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Y ENROL
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h:
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Te
rminatio
n
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PLOYEE
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ION:
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curity
Nu
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Reference Number:
aim
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cator:
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ate
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o
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P
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T INFORM
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MEDI
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0010
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p p
l
y
t
o A
c c
i d
e n
t a
l
De
a
th
a
nd
D
is
m
em
be
r
me
nt
(A
D
&
D)
n
s u
r
a n
c e
a
v a
i l
a b
l e
t h
r
o u g h
yourEmployer,
C
r
a
ny
.
e s
i g
n a
t i
o
n s
a
re
n
ot
a l
i d
u n
l e
s s
s
i g
n e
d ,
d
a t
e d
, a
n
d
e
l i
v e
r e
d
t
o t
h e
E
m
pl
oy
er
d
u r
i n
g
y
o
ur
i f
e t i
m e
.
Se
ep
ag
e
2
o
r
u r
t h
e r
i
n f
o r
m a
t i
F
-
F
u l
l
N
a
me
A
dd
re
s
s
So
c.
e c
.
N
o
.
R e
l a
t i
o n
s h
i
f
e n
e f
.
D
C
,
C
e
C
on
ti
)
e
nt
-
e
A
So
c.
S
ec
.N
o.
R
f
e
n e
f
_
e
t
s
e
con
o
t
e n
y
o
uw
is
h
t o
m
ea
c
a
n
ge
0
d
d
.
e
pe
nd
e
nt
e
l e
t e
D
ep
e
nd
en
t
D
at
e
o
f
d
d /
d e
l e
t e
a
Fo
rm
e
r
in
su
r
an
ce
e
co
m
s
mi
re
.
C
om
pl
et
e
N
a
me
h
an
g
e
n
a
me
a
l l
bo
xe
s
a
nd
e
c t
i o
n s
t h
a t
a p
p l
y .
B
e n
e f
i c
i a
r y
Ch
a
ng
e
O
t h
e r
:
15)
Q
E -
- .
I
wi
s
h
o
m
a
ke
th
e
c h
o i c e s
i n d i c a t e d
on
t h i s
form.f
l e c t i n g
coverage,
u t h o r i z e
d e d u c t i o n s
frommy
ages
t o
cove
r
m
y
o
n t
r i
b u
t i
i
f e q
u i
r
e d
,
t
ow
a
rd
h e
c o
s t
of
n s
u r
a n
c
e .
I
u
nd
er
st
an
d
t h
a t
my
ed
uc
ti
on
a
mo
u
nt
i l
l c
ha
n
ge
f m
y
o
v
er
ag
e
o
r
o s
t s
c
h
an
ge
.
6
, , 7
1
em
b
er
/E
r
n
1
Si
n a
t u
r
e
R
e
qu
ir
e
d
.
d
-
'
1
g
Y
e
e
Da
t
l(
Mo
/
Da
y
/Y
r)
_ _ _
_ _ _
_
H
u
m
an
Re
s
ou
rc
e
sD
ar
t
me
nt
Co
mp
l
et
e
t
h i
s
e
c t
i o
n .
R
et
ai
n
f
o
rm
or
yo
ur
e
c o
r d
s .
D
vs
n
I
D
B
i l
l i
n g
Ca
t. Da
te
o
f
ir
e
/R
eh
ir
e
H
r
s.
Wo
r
ke
d
P
er
W
k
.
Ea
rn
in
gs
$
P
e r
:
i
l l
Ho
u
r
k
i
o
Y
na
11 .
-n ne
l
1
of
2
IND 2
-
7/25/2019 Independence PD Timothy Loehmann Records
14/62
B
ene
fic
iar
y
In f
orm
ati
on
Yo
ur
d e s i
g n a t
i o n
re
vok
es a
l l
p r i o
r d
e s i g
n a t i
o n s .
e
n e f
i t s
a r e on l
y
pa
y abl
e t o
a
c o n t
i n g
e n t
B
e n e
f i c i
a r y
i f y
ou
a r e
n o
t s
u r v i
v e d b
y on e
o
r
mor
e
p
rima
ry
B e n
e f i c i
a r y (
i e s )
.
f
y ou
nam
e
tw
o or
mo r
e
e n
e f i c
i a r i
e s
i
n
a l a s s
:
1 .
Two
r mo
r e
s u r v
i v i
n g
B e n
e f i c
i a r i
e s
w i l l
s h a r
e .
q u a
l l y ,
u n l e
s s y o
u
pr
ovid
e
f o r
une
qua l
s h a r
e s .
2.
I
f
y
ou pr
ov id
e f o r
u
n e qu
a l
h a
r e s i
n a
c l a s
s ,
a n d
t
wo
o
r
m or
e
B e n
e f i c
i a r i
e s
i n
t h a
t c l a s s
s u r
v i v e
,
we
i
l l
p a
y
e
a c h
s
u r v i
v i n
g
B e n
e f i c
i a r y
h i
s o
r
he
r
d e s
i g n
a t e d
s h a r
e . Un
le ss
y ou
p
r o v i
d e
o t h e
r w i s
e , w
e
i
l l
t
h e n
p a y
t h
e
s h a
r e ( s
)
o
t h e
r w i s
e
d ue
to
a
n y d
ecea
sed
B e n
e f i c
i a r y
( i e s
)
t o
t
h e
s u r v
i v i n
g B
e n e f
i c i a
r i e s
p
ror a t
a
ba
sed
o
n
t h
e
r
e l a t i
o n s h
i p t
h a t
the d
e s i g
n a t e
d
pe
rcen
ta ge
or
f
r a c t
i o n a
l s
h a r e
of
eac
h
s u r v
i v i n
g
B e
n e f
i c i a
r y
b e
a r s
t o
t h
e
t o t a
l
s h a r
e s of l
l
s u r
v i v i
n g B e
n e f i
c i a r
i e s .
3 .
If
on
ly
on e
e n e
f i c i
a r y
i n
a
l a s
s s u r v
i v e s
,
w
e
i l l
p a
y
t
h e t
o t a l
d
e a t h
b e n e
f i t s
t o t
h a t
B e n e
f i c i
a r y .
If
a
mi n or
(a
person
n ot
o f
e g a l
a g e ) ,
or
y our
e s t a t e ,
i s
t h e
B e n e
f i c i
a r y ,
t ma
y
e
n e c e
s s a r
y t
o ha ve
a
u a
r d i a
n
or a
l e
g a l
r e p r
e s e n
t a t i
v e
a
ppo
inte
d b
y
h e c
ourt
e
f o r e
a n
y de
ath
b e n
e f i t
c
a n
b e p
a i d .
If
h e B e n
e f i c
i a r y
i s
a
r u
s t
or
t
r u s t e
e ,
t
h e
w r
i t t e
n
t r u s t
mu
st
b e
i d
e n t i f
i e d
i
n
t h e
B e n
e f i c
i a r y
d e s i
g n a t
i o n .
F
or e
xamp
le ,
D
or o
thy
Q. mi
th,
Tru
stee
un
d er
h e
t
r u s t
a
g r e
e me
n t
date
d
A
owe
r o
f
t t o
r n e y
mu
s t
gr
ant
s
p e c i
f i c
a u t h
o r i t
y , b
y t
h e te
r mso
f
h e
d o
cum e
n t or
a p p
l i c a
b l e
l
a w,
o
ma
ke
o
r
c
ha n
g e
a
B e n
e f i
c i a r
y d e s i
g n a t
i o n .
I f
y o
u
h
a v e
a n y
q u
e s t i
o n s ,
c
o n s u
l t
y ou
r
e g
a l
a
d v i s
o r .
e p
e n d e
n ts
I n
s u r a
n c e ,
i f a n y
, s
pa
yabl
et
o
y ou
,
f
i
v i n g
, or
as
pro
vide
d un d
e r
your
Emp l
oy er
's
co
ver
age
un
d er
the
Gr o
up
P o l
i c y .
C
r7qz1
r) 2
f
2
(a /0
3)
IND 3
-
7/25/2019 Independence PD Timothy Loehmann Records
15/62
E n r o l l m e n t
A p p l i c a t i o
h a n g e / C a n c e l l a t i o n
R e q u e s t
To
Be
C o m p l e t e d
By
m p l o y e r
X
E n r o l l
~
C a n c e l
L I
Change
J 1
U n i t e d l l e a l t h e a r
A
n i t e d H e a l t h
Grop c p a n y
E l
A d d r e s s
C h a n g e
E
ame
h a n g e
D a t e
o f
C h a n g e
/
/
ATTENTION
EMPLOYER REPRESENTATIVE:
o e n s u r e
a c c u r a t e p r o c e s s i n g o f
a p p l i c a t i o n ,
1)
l e a s e
r e v i e w
a l l
s e c t i o n s
a n d
c o n f i r m
t h e
employee
c o m p l e t e d
t h e
a p p r o p r i a t e i n f o r m a t i o n , 2)
o m p l e t e
t h e
i n f o r m a t i o n i n
t h i s s e c t i o n
a n d
3)
r o v i d e
y o u r
s i g n a t u r e
a n d
t o d a y ' s
d a t e .
f t h e
employee
s w a i v i n g
c o v e r a g e , do n o t
s u b m i t
t h e
a p p l i c a t i o n
b u t
r e t a i n i t
f o r y o u r r e c o r d s .
Company
ao
r o u p
#
D e p a r t m e n t
#
P l a n
V a r i a t i o n
M e d i c a l ' 7
4
V i s i o n
R e p o r t i n g
M e d i c a l
D e n t a l
Code
V i s i o n
B e n e f i t
L e v e l / C l a s s
L i f e / A D & D
C o d e , f
a p p l i c a b l e
S u p p l .
L i f e
S u p p l .
AD&D
D e n t a l ' - - / - ,
L i f e
L i f e
Spouse
i f e
-
7/25/2019 Independence PD Timothy Loehmann Records
16/62
B. a m i l y ' I n
o r m a t i o n
L i s t
A l l
E n r o l l i n g / C h a n g i n g / C a n c e l l i n g
( A t t a c h
s h e e t
f n e c e s s a r y )
C h e c k
a p p r o p r i a t e
b o x
L a s t
Name
F i r s t
Name
M
I ull
Sex
R e l a t i o n s h i p * * B i r t h d a t e
T i m e
S t u d e n t * * *
P h y s i c i a n * ( F i r s t
a n d
L a s t
Name)
P h y s i c i a n ' s
I D
Number
S o c i a l
S e c u r i t y
Number
L i E n r o l l
0 a n c e l
n h a n g e
M
F
Spouse
1
1 1
i l
I I
R a c e
C h e c k a l l t h a t
a p p l y
( O p t i o n a l ) * * * *
7m e r i c a n
I n d i a n / A l a s k a
N a t i v e
D
s i a n
o
a t i v e
H a w a i i a n / P a c i f i c
I s l a n d e r 0
h i t e
o
l a c k / A f r i c a n - A m e r i c a n
7
i s p a n i c / L a t i n o
E
t h e r P l e a s e
s p e c i f y
P r i m a r y
C a r e
D e n t i s t
Number*
c n r o l l
o
a n c e l
El
C h a n g e
M
F
D e p e n d e n t
E i Y e s
0 o
l
1
R a c e
C h e c k
l l
t h a t
a p p l y
( O p t i o n a l ) * * * *
0
m e r i c a n
I n d i a n / A l a s k a
N a t i v e
o
s i a n
0
a t i v e
H a w a i i a n / P a c i f i c
I s l a n d e r
0
h i t e
E
l a c k / A f r i c a n - A m e r i c a n
7
i s p a n i c / L a t i n o
7
t h e r P l e a s e
s p e c i f y
P r i m a r y C a r e
D e n t i s t
Number*
c
n r o l l
D
a n c e l
C h a n g e
M
F
D e p e n d e n t
E
e s
o o
cil
ill
Race
C h e c k
l l
t h a t
a p p l y
( O p t i o n a l ) * * * *
0
m e r i c a n
I n d i a n / A l a s k a N a t i v e
o
s i a n
o
a t i v e
H a w a i i a n / P a c i f i c
I s l a n d e r
0 h i t e
E
l a c k / A f r i c a n - A m e r i c a n
1 7 1
H i s p a n i c / L a t i n o
7
t h e r P l e a s e
s p e c i f y
P r i m a r y
C a r e
D e n t i s t
Number*
E D
E n r o l l
El C a n c e l
C h a n g e
R a c e
C h e c k
o m e r i c a n
7a t i v e
M
F
D e p e n d e n t
0
e s
u o
P r i m a r y C a r e
D e n t i s t
Number*
1
1
l
1
a l l t h a t
a p p l y
( O p t i o n a l ) * * * *
I n d i a n / A l a s k a
N a t i v e
o
s i a n
H a w a i i a n / P a c i f i c
I s l a n d e r
0 h i t e
I E
B l a c k / A f r i c a n - A m e r i c a n
7
t h e r P l e a s e
o
i s p a n i c / L a t i n o
s p e c i f y
c
n r o l l
D a n c e l
E l
C h a n g e
M
F
D e p e n d e n t
E l Y e s
D o
1
[
i 1
i
1 (
Race
C h e c k a l l
t h a t
a p p l y
( O p t i o n a l ) * * * *
o
m e r i c a n
I n d i a n / A l a s k a
N a t i v e
7
s i a n
B l a c k / A f r i c a n - A m e r i c a n 7
i s p a n i c / L a t i n o
D
a t i v e H a w a i i a n / P a c i f i c i s l a n d e r
0
h i t e
0
t h e r P l e a s e
s p e c i f y
P r i m a r y
C a r e
D e n t i s t
Number*
*
IMPORTANT:
l e a s e
s e e e m p l o y e r
r e p r e s e n t a t i v e
a s
some
p l a n s
r e q u i r e
a
P r i m a r y
P h y s i c i a n
( P r i m a r y C a r e )
a n d / o r
a
P r i m a r y
C a r e
D e n t i s t
(PCD)
e l e c t i o n .
**
o r
some
a s e s ,
s u c h a s
Q u a l i f i e d
M e d i c a l
C h i l d
S u p p o r t ,
a d d i t i o n a l
d o c u m e n t a t i o n
may
b e
r e q u i r e d .
P l e a s e s e e
e m p l o y e r
r e p r e s e n t a t
f o r
more
n f o r m a t i o n .
***
l e a s e
s e e
e m p l o y e r
r e p r e s e n t a t i v e
f o r
s t u d e n t
s t a t u s
q u a l i f i c a t i o n s .
*'
a t a
c o l l e c t e d
w i l l
b e
u s e d
o n l y
t o h e l p
c o m m u n i c a t e w i t h
e n r o l l e e s a n d
i n f o r m
them
o f
s p e c i f i c
p r o g r a m s t o
e n h a n c e t h e i r
w e l l - b e i n
a n d n o t
f o r
e l i g i b i l i t y o r c l a i m
payment
e t e r m i n a t i o r r r
C. r o d u c t
P e r s o n
S e l e c t i o n
M e d i c a l
D e n t a l
P l e a s e
c h e c k
a l l
t h a t
a p p l y .
B e n e f i t
o f f e r i n g s a r e d e p e n d e n t
u p o n
e m p l o y e r
e l e c t i o n .
D u a l
O p t i o n
P l a n
S e l e c t e d
Vision
L i f e / A m o u n t
Sup
L i f e
Sup
AD&D
ST D
L T D
E m p l o y e e
Spouse
D e p e n d e n t s
0
E l
E
E
E l
I:
E
D
E
E l
-
. . , - - - -
s
.
I l s 4 4 1
,
.
1
, ', ..
' -
-
-
E
----------
" : 1 11
: r 1 " 4 z I t t * .1
"1.:4.*
'11
_ -
-
' ' . .
. .
,
0
: - r:c
o i P
W
. t z
;
D
-
,
,' i
,
4,/
, .
'
i . :
5 4 ;
,
.
,
,t -
r
. . - . 4 . .
0
0
alary
R e q u i r e d
o n l y
i f
L i f e
P l a n b a s e d
o n
s a l a r y
L i f e
I n s u r a n c e
B e n e f i c i a r y ' s F u l l
Name
a n d
A d d r e s s
R e l a t i o n s h i p
P a g e
2 f 4
IND 5
-
7/25/2019 Independence PD Timothy Loehmann Records
17/62
D.
t h e r
M e d i c a l
C o v e r a g e
I n f o r m a t i o n
T h i s s e c t i o n
m u s t
b e
c o m p l e t e d .
{ A t t a c h s h e e t f n e c e s s a r y . )
On t h e d a y
t h i s
c o v e r a g e b e g i n s ,
w i l l y o u ,
y o u r
s p o u s e o r
a n y o f y o u r
d e p e n d e n t s
b e c o v e r e d u n d e r a n y
o t h e r
m e d i c a l h e a l t h
p l a n o r
p o l i c y ,
i n c l u d i n g
a n o t h e r
U n i t e d H e a l t h c a r e
p l a n o r
M e d i c a r e ?
YES c o n t i n u e
c o m p l e t i n g
t h i s s e c t i o n )
c
O s k i p t h e r e s t o f t h i s s e c t i o n )
Name
f
o t h e r
c a r r i e r
O t h e r
G r o u p M e d i c a l C o v e r a g e - I n f O r m a t i o n
( o n l y
l i s t
t h o s e c o v e r e d
b y
o t h e r
p l a n )
T y p e
( B / S / F ) *
E f f e c t i v e D a t e
E n d
D a t e
Name
a n d d a t e o f b i r t h o f
p o l i c y h o l d e r
f o r
o t h e r
c o v e r a g e
r o u s e
Name:
D e p e n d e n t
Name:
D e p e n d e n t
Name:
D e p e n d e n t Name:
* B . E n t e r
B '
w h e n t h i s d e p e n d e n t i s
c o v e r e d u n d e r
b o t h
y o u a n d y o u r s p o u s e ' s in s u r a n c e p l a n
( m a r r i e d )
S . E n t e r
S '
f y o u
a r e
t h e p a r e n t
a w a r d e d c u s t o d y o f t h i s
d e p e n d e n t
a n d
n o o t h e r
i n d i v i d u a l
i s
r e q u i r e d t o p a y
f o r
h i s
d e p e n d e n t ' s m e d i c a l e x p e n s e s ,
E E n t e r
F '
i f
t h i s d e p e n d e n t
i s
c o v e r e d
b y
a n o t h e r
i n d i v i d u a l
( n o t
a
member f
y o u r
h o u s e h o l d )
e q u i r e d
t o p a y
f o r
t h i s d e p e n d e n t ' s m e d i c a l
e x p e n s e
M e d i c a r e E m p l o y e e
I n f o r m a t i o n :
I f
e n r o l l e d
i n M e d i c a r e ,
p l e a s e
a t t a c h
a
c o p y
o f y o u r
M e d i c a r e I D c a r d .
E n r o l l e d
i n P a r t
A :
f f e c t i v e
D a t e I n e l i g i b l e f o r P a r t
A*
N o t E n r o l l e d i n P a r t
A
c h o s e
n o t t o
e n r o l l )
E n r o l l e d
i n
P a r t
B :
E f f e c t i v e
D a t e
D
n e l i g i b l e
f o r P a r t
fr
n
o t
E n r o l l e d
i n
P a r t
B
c h o s e
n o t
t o
e n r o l l )
i n
E n r o l l e d i n P a r t D: f f e c t i v e
D a t e I n e l i g i b l e f o r
P a r t
D' N o t E n r o l l e d
i n
P a r t D c h o s e n o t
t o
e n r o l l )
R e a s o n f o r
M e d i c a r e
e l i g i b i l i t y : O v e r
65
K i d n e y D i s e a s e
D i s a b l e d D i s a b l e d
b u t a c t i v e l y a t w o r k
M e d i c a r e
S p o u s e / D e p e n d e n t
Name:
E n r o l l e d i n
P a r t
A :
f f e c t i v e D a t e
E n r o l l e d i n
P a r t B : f f e c t i v e
D a t e
E n r o l l e d i n P a r t D :
f f e c t i v e D a t e
I n e l i g i b l e f o r P a r t
A*
o
o t
E n r o l l e d i n
P a r t
A
( c h o s e n o t
t o e n r o l l )
I n e l i g i b l e f o r
P a r t B*
E l N o t E n r o l l e d i n
P a r t
B
c h o s e
n o t t o
e n r o l l )
I n e l i g i b l e f o r P a r t D* N o t E n r o l l e d
i n
P a r t D c h o s e
n o t t o
e n r o l l )
R e a s o n f o r M e d i c a r e e l i g i b i l i t y :
O v e r
65
K i d n e y
D i s e a s e D i s a b l e d D
i s a b l e d
b u t
c t i v e l y a t w o r k
* O n l y
c h e c k
I n e l i g i b l e "
i f
y o u
h a v e r e c e i v e d d o c u m e n t a t i o n
f r o m
y o u r
S o c i a l
S e c u r i t y
b e n e f i t s t h a t
i n d i c a t e
t h a t
y o u
a r e
n o t e l i g i b l e
f o r
M e d i c a r e
E .
W a i v e r
o f
C o v e r a g e
I d e c l i n e
c o v e r a g e f o r :
0 y s e l f
o
pouse
D e p e n d e n t
C h i l d r e n
M y s e l f
a n d
a l l
d e p e n d e n t s
F .
t r g i a t i i i i
7
D e c l i n i n g
c o v e r a g e d u e
t o
e x i s t e n c e o f
o t h e r
c o v e r a g e :
S p o u s e ' s E m p l o y e r ' s P l a n I n d i v i d u a l P l a n
C o v e r e d
b y
M e d i c a r e
M e d i c a i d
COBRA r o m P r i o r
E m p l o y e r
VA
l i g i b i l i t y
T r i - C a r e
0
(we)
a v e
n o o t h e r c o v e r a g e a t
h i s t i m e
O t h e r
I u n d e r s t a n d
t h a t
b y
w a i v i n g
c o v e r a g e a t
t h i s t i m e ,
w i l l n o t
b e
a l l o w e d t o
p a r t i c i p a t e
u n l e s s I
e x p e r i e n c e
l i f e
c h a n g e
e v e n t ,
a t
t h e n e x t
o p e n
e n r o l l m e n t
p e r i o d
a s a l a t e
e n r o l l e e ,
f
a p p l i c a b l e .
a c k n o w l e d g e
t h a t I
h a v e r e c e i v e d t h e
" I m p o r t a n t
I n f o r m a t i o n "
s t a t e m e n t
w h i c h i s
i n c l u d e d
w i t h
t h i s
f o r m .
m p l o y e e I n i t i a l s ,
D a t e
l c o n f i r m
t h a t
t h e
i n f o r m a t i o n
I h a v e p r o v i d e d on h i s f o r m
i s
c o m p l e t e a n d a c c u r a t e .
I u n d e r s t a n d
t h a t t h e h e a l t h
b e n e f i t
p l a n t h a t
h a v e
s e l e c t e d
p r o v i d e s r e i m b u r s e m e n t f o r c e r t a i n
m e d i c a l
c o s t s , w h i c h a r e more u l l y d e s c r i b e
i n
t h e
c u r r e n t
C e r t i f i c a t e o f
C o v e r a g e . I u n d e r s t a n d t h e r e
may
b e i n s t a n c e s w h e r e
t r e a t m e n t
d e c i s i o n s
made
b y
my
h y s i c i a n
o r me
r
m e d i c
e x p e n s e s
w h i c h f h a v e i n c u r r e d
may
n o t b e c o v e r e d b y
my
h e a l t h
b e n e f i t
p l a n .
I
u n d e r s t a n d t h a t i n f o r m a t i o n
c o l l e c t e d i n c o n n e c t i o n
w i t h a d m i n i s t r a t i o n
o f t h e b e n e f i t
p l a n
may
b e u s e d
t o
b r i n g
t o my
t t e n t i o n
h e a l t h
p r o d u c t s
o r
s e r v i c e s t h a t
m i g h t
b e
v a l u a b l e
t o
me
n d
o t h e r w i s e
a s
p e r m i t t e d
b y
l a w .
I
u n d e r s t a n d
t h a t
y o u
may
o m b i n e
t h a t
i n f o r m a t i o n
w i
o t h e r i n f o r m a t i o n so h a t t i s
n o l o n g e r i n d i v i d u a l l y i d e n t i f i a b l e a n d u s e i t f o r
c o m m e r c i a l
a n d o t h e r
p u r p o s e s .
I
a c k n o w l e d g e t h a t
h a v e
r e c e i v e d
t h e
" I m p o r t a n t I n f o r m a t i o n "
s t a t e m e n t w h i c h
i s i n c l u d e d
o n t h e b a c k
o f
t h i s
f o r m .
Any p e r s o n
who, i t h i n t e n t t o
d e f r a u d
o r k n o w i n g t h a t h e
i s
f a c i l i t a t i n g a f r a u d a g a i n s t a n
i n s u r e r ,
s u b m i t s
a n
a p p l i c a t i o n o r i l e s
a
c l a i m
c o n t a i n i n g
a
f a l s e
o r
d e c e p t i v e s t a t e m e n t i s g u i l t y
o f i n s u r a n c e f r a u d .
D a t e
E m p l o y e e S i g n a t u r e f r a l l
a p p l y i n g
li
a i v i n g
Spouse
i g n a t u r e i f a p p l y i n g
f o r
c o v e r a g e )
P r i m a r y
L a n g u a g e Spoken
CIEn.
s h
S p a n i s h O t h e r
P a g e
3 f
4
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7/25/2019 Independence PD Timothy Loehmann Records
18/62
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7/25/2019 Independence PD Timothy Loehmann Records
19/62
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h
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o
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er
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p l i
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ma
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20/62
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co
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IND 9
-
7/25/2019 Independence PD Timothy Loehmann Records
21/62
-
7/25/2019 Independence PD Timothy Loehmann Records
22/62
S e
c t
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r i
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4
N
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2
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1 7
1
S t
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w a
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:
F
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on
F
u
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D e l
i v
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Me
mb
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e r
v i c
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/ P a
y r o
l l
C
o n
t r i
b u
t i o
n s
Gr
ou
p
P a
g e
2
