10-26-2018 - Special ���,� �/ 104 N. Riverside Drive
"�` C�t1 �f EdgeWater Edgewater, FL32132
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��GEtivATER Meeting Agenda
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City Council - Special Meeting
Friday, October 26,2018 10:00 AM Council Chambers
Sgt. Burris - Separation Procedure
We respectfully request that all electronic devices are set for no audible notification.
1. CALL TO ORDER&ROLL CALL
2. OTHER BUSINESS
a. Special Council Meeting to discuss Sgt. Adam Burris Family Medical Leave Act(FMLA)
Separation Procedure
Attachments: Memorandum ref Sqt Adam Burris Separation 10-18-18
3. ADJOURN
Pursua�t to Chapter 286, F.S., if a� i�dividual decides to appeal a�y decisio�made with respect to a�y
matter co�sidered at a meeti�g or heari�g, that i�dividual will�eed a record of the proceedi�gs a�d
will�eed to e�sure that a verbatim record of the proceedi�gs is made. The City does�ot prepare or
provide such recorc�
I�accorda�ce with the America�s with Disabilities Act,perso�s�eedi�g assista�ce to participate i�a�y
of these proceedi�gs should co�tact City Clerk/Paralegal Robi�L. Matusick, 104 N. Riverside Drive,
Edgewater, Florida, telepho�e�umber 386-424-2400 x 1102, S days prior to the meeti�g date. If you
are heari�g or voice impaired, co�tact the relay operator at 1-800-955-8771.
City of Edgewater Page 1 Printed on 10/22/2018
104 N. Riverside Drive
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City of Edgewater Edgewater, FL 32132
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EDGEINATER
Legislation Text
File #: AR-2018-3792, Version: 2
COUNCIL AGENDA ITEM
SUBJECT:
Special Council Meeting to discuss Sgt. Adam Burris Family Medical Leave Act(FMLA) Separation Procedure
DEPARTMENT:
City Manager
SUMMARY:
On October 16, 2017 the majority of the City Council had requested a Special City Council meeting for the
purpose to discuss the policy and procedures associated with the separation of employment with Sgt. Adam
Burris.
On October 18, 2018 the City Manager provided the City Council with a detailed report outlining, in a
chronologic order, the events and occurrences that had occurred throughout the Family Medical Leave Act
(FMLA)period. The report is attached to this Agenda Request.
BUDGETED ITEM: ❑ Yes � No ❑ Not Applicable
BUDGET AMENDMENT REQUIRED: ❑ Yes ❑ No � Not Applicable
RECOMMENDED ACTION:
Direction provided to staff regarding the future handling of Sgt. Adam Burris' FMLA separation and any
additional amendments to current Policies and Procedures and/or Collective Bargaining Agreements regarding
FMLA separation procedures.
City of Edgewater Page 1 of 1 Printed on 10/22/2018
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INTER-OFFICE MEMORANDUM
TO: City Council
FROM: Tracey T. Barlow, City Manager ��
DATE: October 18, 2018
SUBJECT: Sergeant Adam Burris Separation
The purpose of this memorandum is to describe the timeline and occurrences leading up
to the separation of employment of Sergeant Adam Burris.
Sgt. Burris is a 6 year veteran with Edgewater Police Department with 2 years in grade as a
Police Sergeant. On the evening of January l, 2018 Sgt. Burris and his assigned shift responded
to a domestic violence incident involving a male and female. Shortly after arrival they
encountered a male subj ect actively shooting at the female as she exited the residence.
Immediately thereafter the officers exchanged gunfire after the male subj ect would not drop his
gun. The male subject was subsequently fatally shot by another officer on-scene. As procedure
protocol all officers that were involved in this officer involved shooting were placed on
Administrative Leave effective January 2, 2018. The purpose of the Administrative Leave is for
the Florida Department of Law Enforcement (FDLE) to complete a preliminary investigation as
well as have the involved officers evaluated by a Licensed Psychologist. On January 6, 2018 all
involved officers had been cleared to return to normal service (36 hours Paid Administrative
Leave).
April 13, 2018 Sgt. Burris reported to Captain Mahoney that he believed to have a non-physical
injury as a result of the January l, 2018 shooting incident. Once the non-physical injury was
reported to the Human Resources Department a Workers Compensation claim was immediately
filed. In accordance with Florida Statute at that time Workers Compensation would only
authorize and cover the cost of inedical treatment as the condition is considered without physical
injury. Subsequently, on April 13, 2018 Sgt. Burris was provided and signed a letter describing
`7t is imperative that you notify the Personnel Department of your doctor's appointments and
obtain a Work Status Report form from us to take to your doctor each time you visit them." It
Office of the Citv Mana�er
P.O. Box 100• Edgewater, FL 32132-0100
(386) 424-2400 Ext. 1201 • Fax(386) 424-2421
www.cityofedgewater.org
further states "You may not return to work until you have personally given this information to
the Human Resources Department. " The letter also provides an opportunity for those employees
that work outside of the regular Monday thru Friday schedule to contact the Human Resources
Department by phone to provide their updates. (Document attached)
On April 13, 2018 after Sgt. Burris reported his injury, he was immediately placed on Paid
Administrative Leave and assigned treatment. The Paid Administrative Leave occurred from
April 13, 2018 —May 7, 2018 (152 hours).
May 7, 2018 Sgt. Burris was released by his physician to return to regular duties with no
restrictions. Sgt. Burris worked without restrictions until May 22, 2018.
May 25, 2018 Sgt. Burris was restricted by his physician to administrative duties only, unable to
perform road duties at this time. Sgt. Burris began using his accruals through June 6, 2018.
May 29, 2018 Human Resources Director, Julie Christine, met with Sgt. Burris and hand
delivered the Family Medical Leave Act paperwork and discussed the light/modified duty
options that were within consideration based on the limitations that his physician has placed on
him. Sgt. Burris expressed interest in any applicable positions available in order to preserve the
depletion of his accrual time. (Notes attached)
May 30, 2018 Sgt. Burris's physician temporarily restricted him from performing his regular
duties stating he currently cannot make critical decisions as required of a law enforcement
officer.
June 5, 2018 the Human Resources Director met with Sgt. Burris and offered him a modified
duty job position in the code enforcement division. Sgt. Burris accepted the position and began
June 6, 2018. (Document attached)
June 7, 2018 Sgt. Burris completed 16.8 hours of work with the code enforcement division and
advised that he could no longer continue as working in the city of Edgewater acerbated his
condition. Sgt. Burris also returned to his physician who restricted him from performing any
work based on the findings of his evaluation.
June 7, 2018 thru October 2, 2018 it is assumed that Sgt. Burris had continued treatment
although follow-up reports were not communicated to the Human Resources Department. During
this period Sgt. Burris was utilizing his accrual time.
June 8, 2018 Police Pension Board Administrator sent Sgt. Burris requested paperwork for the
Application of Permanent Disability.
July 18, 2018 Police Pension Board Administrator received paperwork from Sgt. Burris's
attorney, Tony Oliver.
August l, 2018 Human Resources Director, Julie Christine mailed Sgt. Burris the Long Term
Disability Claim Employee's Statement, Authorization to Disclose Personal Information, along
with the Long Term Disability Physician's Statement.
Office of the Citv Mana�er
P.O. Box 100• Edgewater, FL 32132-0100
(386) 424-2400 Ext. 1201 • Fax(386) 424-2421
www.cityofedgewater.org
August 7, 2018 Human Resources Director, Julie Christine completed the Long Term Disability
Employer's Statement and submitted to the City's Long Term Disability Carrier, Mutual of
Omaha.
August 23, 2018 Sgt. Burris had stopped by the Human Resources Department and spoke with
Brooke Appy asking questions regarding Long Term Disability (LTD) benefits. During such
conversation he had mentioned his desire to separate from "this place, specifically the police
department" because of the stress it was creating on his condition.
September 5, 2018 The Police Pension Board Attorney, Ken Harrison, received the medical
records and an Independent Medical Evaluation (IME)was set-up for October 3, 2018.
October 2, 2018 the Human Resources Director had mailed a certified letter to Sgt. Burris
describing that the twelve (12) weeks of the Family Medical Leave Act (FMLA) was exhausted
as of August 3, 2018 and that the 900 hours afforded to him in accordance with Article
ll(Injuries) of the Police Benevolent Association (PBA) Collective Bargaining Agreement
(CBA)will have been exhausted as of October 9, 2018. The letter further states that his physician
has reported "that you can no longer perform any duties related to law enforcement and working
in the City of Edgewater is a further harm to your health." The letter further provided for a
separation of employment date effective October 10, 2018.
October 11, 2018 a Long Term Disability check of $2,855.83 was mailed to Sgt. Burris. The
Long Term Disability qualifying effective date was June 8, 2018. Additional monthly Long
Term Disability payments are expected to be $2,55433/month. Amounts may change based on
Sgt. Burris's selection of federal withholdings.
October 25, 2018 is the date that is scheduled for Sgt. Burris's remaining accruals (355 hours at
$22.84) to be cashed-out at a value of$8,108.20, before tax deductions, and will be issued to Sgt.
Burris.
October 31, 2018 is the date that Sgt. Burris city provided healthcare insurance is scheduled to
terminate. (As a supervisor employee Sgt. Burris was provided 100% employee coverage and
75% dependent coverage. He had selected Single Parent Health and Dental coverage. Health
Insurance - city cost $1,215.14/month and employee cost $$140.74/month; Dental - city cost
$50.26/month and employee cost $16.74/month)
In accordance with Ordinance 2017-0-21 Sgt. Burris may qualify for Line-of-Duty Injury Health
Insurance Benefit as outlined in Section 5.04 of the Police Pension Plan amended on June 5,
2017. As provided for in paragraph (a) Eligibility for this benefit shall be determined by the
Police Pension Board Trustees. (Ordinance attached)
From January l, 2018 thru October 10, 2018 Sgt. Burris received absentee compensation at
$22.17/hr. from the following accounts:
Sick accruals used - 540 hours
Vacation accruals used - 259.20 hours
Floating Holiday used- 48 hours
Holiday - 24 hours
Administrative lea�e - 188 hours
Office of the Citv Mana�er
P.O. Box 100• Edgewater, FL 32132-0100
(386) 424-2400 Ext. 1201 • Fax(386) 424-2421
www.cityofedgewater.org
From January l, 2018 thru October 10, 2018 the following accrual hours were credited to Sgt.
Burris's accrual banks:
Vacation hours- 108 hours
Sick hours - 72 hours
October 15, 2018 Councilman Conroy had sent me an email expressing his concerns regarding
the separation status of Sgt. Burris. He had also referenced that he had sent the Mayor an email
requesting a Special Council Meeting to discuss the topic.
October 16, 2018 at the noticed Whistle Stop walkthrough progress visit with the all of the City
Council, with the exception of Councilman Conroy, I had pooled the interest of the attending
Council members regarding having the requested Special City Council meeting as it was brought
to my attention that Sgt. Burris had previously emailed all of them regarding his complaint. The
majority confirmed interest and I later coordinated the date of October 26, 2018 at 10:00 AM in
the City Council Chambers.
October 17, 2017 City staff has been advised by the office of the Police Pension Attorney that
the Independent Medical Evaluation had been completed by the Board appointed physician and
hard copy should have been mailed last week, although they have yet to receive them. They have
also advised that the informal hearing at which the disability application of Sgt. Burris will be
considered has not yet been set but can either take place at the Board's next regularly scheduled
meeting and/or the Board may choose to hold a special meeting once the Independent Medical
Evaluation is received and the disability record compiled.
October 17, 2018 I telephoned the Police Benevolent Association (PBA) representative, Mike
Scudiero, to ensure he was aware of the scheduled Special Council meeting to discuss the topic
of Sgt. Burris's separation. He confirmed he was aware and had discussed such with Sgt. Burris
the previous date. He had also confirmed that he hadn't previously had conversation with Sgt.
Burris regarding this subject since the June time period. I also discussed my interpretation of
Article ll (Injuries) of the Police Benevolent Association (PBA) Collective Bargaining
Agreement (CBA) which states: "The injured employee will remain on workers' compensation
status, not to exceed six hundred (600) hours (nine hundred (900) hours for those on Platoon
System). If, as a direct result of the continuation of the disability involved, the employee is
unable to return to work at the end of this time period, the employee may petition the DCR
[Designated City Representative, shall mean the City Manager or his appointed representativeJ
requesting that the employee be carried beyond the established time period." Mr. Scudiero was
in agreement regarding my understanding of the not to exceed 900 hours verbiage without the
extension request of the employee. I had advised that as of this date I had not received any
extension request as afforded in the Collective Bargaining Agreement. I had also advised I didn't
believe I had a good understanding of Sgt. Burris' concerns/requests. I only understood he was
dissatisfied because he did not receive a telephone call regarding separation prior to receiving
written notice. I suggested the 3 of us (Burris, Scudiero and myself) meet in order for me to be
able to provide a reasonable and amicable recommendation to the City Council. He concurred
and later called me back confirming a meeting time for October 18, 2018 at 10:30 AM.
Office of the Citv Mana�er
P.O. Box 100• Edgewater, FL 32132-0100
(386) 424-2400 Ext. 1201 • Fax(386) 424-2421
www.cityofedgewater.org
October 18, 2018 I met with Sgt. Burris and Mike Scudiero in my office. I understood Sgt.
Burris's concerns to be in which the way the process was handled. His major concern was the
fact he thought he would be permitted to exhaust all of his accruals before being separated.
During such discussion he did acknowledge the provision within Article 11 of the Collective
Bargaining Agreement was his responsibility but had wished it was specifically pointed out to
him during the process. It was also expressed he should have been given more notice of the
impending separation date with a face-to-face conversation versus receiving a certified letter a
couple of days prior to the separation date. I recognized his concerns and concurred there was
opportunity to do better with future similar occurrences. We discussed a good corrective action
would be to bring the employee in approximately 30-days prior to separation date and walk them
through as to what to expect. This would allow the employee ample time to address any
additional insurance transitions. He also suggested management could improve with more caring
follow-up during the period of absence.
His request was to have his insurance, as he will receive it upon eligibility confirmation by the
Police Pension Board, continued beyond his separation date and until such time the Police
Pension Board either confirms or denies eligibility. He expressed his intent with bringing his
experience to the attention of the city administration and City Council was to help improve the
process going forward. We discussed the opportunity in having the Collective Bargaining Unit as
well as the City Council to consider a Memorandum of Understanding (MOU) that would amend
Article 11 (Injuries) of the Collective Bargaining Agreement. The amendment would address the
gap regarding insurance coverage between the time the disabled employee is separated from
employment and the time the Police Pension Board of Trustees evaluates benefit eligibility. It
was discussed to possibly consider a maximum of a 90-day period the employee would continue
insurance coverage, as they would receive it upon eligibility confirmation by the Police Pension
Board.
Upon conclusion of the meeting it was agreed that I would recommend to the City Council that
we continue his insurance coverage, as he will receive it upon eligibility confirmation by the
Police Pension Board, until such time the Police Pension Board Trustees considers his benefit
eligibility. It was also agreed that I would discuss with the City Council their interest in
considering an MOU to address the gap in coverage between employment separation and benefit
eligibility with the Police Pension Board Trustees.
I had provided both Sgt. Burris and Mr. Scudiero a draft copy of this memorandum for their
review. I had agreed to consider any recommendations and/or amendments before the memo is
finalized and distributed. It was also discussed if I was to individually receive authorization from
the majority of City Council members to authorize me to continue his healthcare insurance, as he
will receive it upon eligibility confirmation by the Police Pension Board, would he want for the
City Council to continue the Special meeting if the majority of the Council wishes to canceL I
also advised him if such occurred I would affirm such decision regarding his healthcare
insurance under my report at the November 12, 2018 regularly scheduled City Council meeting
in order to have it on record. I advised him that I did not want that decision at this meeting but
rather for him and Mr. Scudiero discuss as well as review my memo and report get back with me.
Later this afternoon Mr. Scudiero reported they were comfortable with contents of the
memorandum.
Office of the Citv Mana�er
P.O. Box 100• Edgewater, FL 32132-0100
(386) 424-2400 Ext. 1201 • Fax(386) 424-2421
www.cityofedgewater.org
DATE: ���3� �� �
T0: INJURED;EMPLOYEE
FROIv1: HUIv1AN R�SOL7RCES DEPARTMENT
SUBJECT: SCHEDULED DOCTOR'S APPOINTNIENTS
. It is 'imperatia�e that you �-�otify t11e Pei-soni�el `Depai�tinent `ol}�oiii cloctor's appoi»tinents
�uld ol�taiiz a Worl< Status:IZeport form fi�o�i� iis to ta1<e to you�- doctoi• eac�71 tinie you ���sit
them.
You may not returii to wa1-lc ui�til you have personally ;given this inforzrration`to tlze
Hui�7a�� Resources Departii7ent, {Per tl7e Woi�kers Compei�sation Stattiie) For.those of
you w110 work sclzedules outside of Monday.thru Friday; please contact us by pl�one to
discuss the results of your doctor's a�.pointineizts, We will theiz>be tipdated as to your `
status and wi11 be'able to ai�swer any c�uestions fi-orn yotrr departments oi� the worl<ers
compensatioil carrier; if needed.
Plrysical therapy: If�you are scheduled`by a �17ysiciai� to ui7dergo physical therapy; you
should be gi�en a sclied-ule: We-also need a copy of tliis scl7eciule to cooi'cliiiate the needs
:and aizs�ver any qirestions fi'om}�our supervisors, etc.
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Injured ErnpIoyee
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Julie Christine
From: Adam Burris
Sent: Wednesday, May 30, 2018 10:08 PM -
To: Julie Christine
Cc: Joe Mahoney
Subject: FMLA Questions
Julie,
After reviewing the paperwork you provided me for FMLA you have my start date of FMLA as being 4/13/18.That is the
day I notified my supervisor of the incident. On the 4/13 I was placed on admin leave by the Chief. On May 7th I was
cleared by my psychologist to go back to work with no restrictions. I continued to work full duty for the next 3 weeks
and on 5/24/18 is when my doctor restricted me to light duty. Since I am on restricted duty per my doctors orders I
believe my FMLA should be starting on 5/24/18 not 4/13/18.
Can you please clarify in writing the start date of my FMLA in accordance to our contract? Is FMLA put on hold for those
3 weeks I was back to work? Does FMLA go by 12 weeks or by hours being out?Thank you.
Adam Burris
Sent from my iPad
[City Website]<http://www.ed�ewaterfl.gov> [Facebook] <https://www.facebook.com/CityofEd�ewater> [Twitter]
<https://twitter.com/cityofed�ewater> [YouTube]
<https://www.Youtube.com/channel/UCI rOuHACBVupYf2sIPWXkw> [Newsletter]
<http://www.cityofed�ewater.or�/how-do-i/receive-emaii-notifications> [Mobile App]
<http://cportal.operationslob.com/mobile/?appcode=ed�ewaterfl>
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June 5, 2018
Adam Burris
HAND DELIVERED
RE: Modified Duty
Dear Mr. Burris:
Please accept this correspondence as notice of our intent to offer you a modified duty job position
beginning on Wednesday, June 6, 2018. On that date please report to Division Chief, Jeff Lariscy at Fire
Station 55, 1605 S. Ridgewood Avenue to begin your temporary modified duty position in the Code
Enforcement Division. It is our intent that your work shift will start at 8:00 a.m. and end at 4:50 p.m.
Monday-Friday, working a 42 hour work week.
We are aware of your job restrictions of administrative duties only, no road patrol and no life/death
decisions as assigned by Dr. Michael Hoffman. Please be advised the afarementioned light duty job shall
be within those restrictions. If for some reason you believe this position is not within those restrictions
either now or after returning to wark please immediately contact Julie Christine,Human Resources
Director at 386-424-2400, extension#1701.
If you do not intend to accept this position or if you have any questions, issues or problems with respect
to this temporary modified duty job offer, please notify the Human Resources department immediately.
Sincerely,
. ,
� _'��t.. (� ii t(t�-i ft�°_.c:'_
�u .
Julie Christine
Human Resources Director
Human Resources Department
l04 North Riverside Drive
(386)424-2400 Ext. #I701 Fax(386)424-2474
www.cityofedgewater.org
(38s)4z4-24�4 (foX�
Notice: Under Florida law, e-mail addresses are public records. !f you do naf u�ant your e-mail address
released in response to a pub(ic-records request, do nof send electronic mai!to this entity. lnstead;
cantact this office by phone or in writing,
From: Joe Mahoney
Sent: Thursday, June 07, 2018 9:37 PM
To: Julie Christine; Brooke Appy; Tonya Vanek
Cc: Michelle Grenham; Dave Arcieri
Subject: Fwd: Full Pay
Please see below request.
Sent from my iPhone
Begin forwarded message:
From: Adam Burris <aburris cr,CITYOFEDGEWATER.ORG>
Date: June 7, 2018 at 9:14:14 PM EDT
To: Joe Mahoney<jmahone�cr,CITYOFEDGEWATER.ORG>
Subject: Full Pay
Captain Mahoney,
Since I'm back to no work and have to use my sick/vacation time, can you make
sure my pay goes back to my normal rate of$22.17 an hour. Thank you.
Adam
Get Outlook for iOS
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October 2, 2018 CERTIFIED MAIL
������
Adam Burris
Re: Workers Compensation Leave/FMLA
Dear Mr. Burris:
I must inform you that your twelve weeks with the Family Medical Leave Act was exhausted on August 3,2018 and
has been extended beyond the limit.Also, in accordance with Article 11 of the PBA bargaining agreement your 900
hours of workers' compensation status will have been exhausted on October 9, 2018. Your work status provided by
Dr.Michael Hoffman,PHD states that you can no longer perform any duties related to law enforcement and working
in the City of Edgewater is a further harm to your health.As such,your absence and inability to return to work creates
a hardship on the City of Edgewater's operations and I must provide you this notification that we shall separate your
employment with the City of Edgewater, effective October 10, 2018.
On August 1,2018,I submitted your Einployer's Long Term Disability claim form to Mutual of Omaha,our disability
carrier, along with all of the required employer's documentation and information Mutual of Omaha requested. The
employer's portion is completed; however, your claim is still awaiting medical records from your Physician. When
those forms are received, Mutual of Omaha will advise you of your eligibility for benefits or any additional
information that may be required.
Even though you will no longer be eligible for coverage on the City of Edgewater's group health and dental plan after
October 31,2018,you may choose to continue your current family coverage under COBRA. You will be receiving a
separate letter from Cobra Point(City's Cobra Vendor)which will explain your cobra continuation rights and the cost
for purchasing COBRA for both medical and dental coverage.
Additionally,please find enclosed the Conversion of Group Life Benefits to an Individual Policy(life)forms. If you
wish to continue your life insurance coverage,you have thirty-one(31)days from the date ofyour separation to return
this paperwork along with your premium to Mutual of Omaha.
It is also very important that you contact the Human Resources Department for any outstanding benefits/obligations
you have with the City prior to October 15, 2018.
If you have any questions, or if I can be of any assistance, please do not hesitate to contact me.
Sincerely,
`�.�,.��1�.��, �1.r�.,��k �'s';..�
�
Julie Christine
Human Resources Directar
Enclosures
Human Resources Department
104 NoKh Riverside Drive
(386)424-2400 Ext. #1701 Fax(386)424-2474
Life Conversion Coverage
LIFE GOES ON WITH GROUP CONVERSION
Your group life insurance has been valuable protection for you and your family. Now that it will be terminated,you may
wish to convert this important coverage to an individual poliry. This information has been prepared to help you take
advantage of your right to continue your protection.
ABOUT LIFE CONVERSION COVERAGE
Life Conversion Coverage is individual permanent life insurance issued without evidence of insurability.
Life Conversion Coverage can be obtained when your life insurance under the group policy ends.Your group certificate
will describe when conversion coverage is available to you,and will show the amount of coverage you can convert.
Conversion coverage will be issued without evidence of good health,provided:
(a) you complete the attached application,
(b) you enclose a check or money order for the first premium payment and
(c) these items are forwarded to us within 31 days after your group insurance ends.
Your conversion policy will be effective on the 31st day after your group insurance ends.During this 31-day period,you
remain covered under the continued coverage provision of your group certificate.
You may apply for an amount that is not more than the amount of your current group insurance coverage (this is your
maximum).You may elect coverage in$1,000 increments up to your maximum.
The individual poliry is Whole Life Express Insurance,which provides a level benefit throughout your lifetime.Premiums
for this coverage are payable while living until the policy anniversary following age 95.
Premium rates are shown in the table that follows.If premium payments are discontinued,you may:
(a) receive any existing cash value or
(b} use the cash value to purchase extended term insurance or a reduced amount of paid-up life insurance.
For additional information or premium rates on conversion coverage,please write or call us at:
Attn: Group Policy Services,Group Conversion
United of Omaha Life Insurance Company
Mutual of Omaha Plaza
Omaha,Nebraska 68175
Phone: 1-800-826-8054
TO APPLY FOR LIFE CONVERSION COVERAGE
In order to apply for life conversion coverage,you must do the following:
1) Complete the Life Conversion Application that follows.Use black or blue ink,or a typewriter.Write clearly and do not
erase—any corrections should be crossed out and initialed by you.Answer each question fully—do not use dashes or
ditto marks.
2) Make sure the section entitled"Information to be Completed by the Personnel Office"is completed by the employer or
administratar of the group policy.
3) Attach your check or money order payable to United of Omaha Life Insurance Company far the first annual or
semiannual premium payment.
4) Send your premium payment and completed application to the above address within 31 days after your group
insurance ends.
Privaey Notice:When United of Omaha Life Insurance Company evaluates an application for life conversion coverage,anly the information
on the application is reviewed. This information,and other information we may later collect to administer coverage, may sometzmes be
disclosed without your express authorization. We have a procedure which allows you to review and amend any information we collect about
you—other than information relating to a clazm,lawsuit or criminal proceeding.If you would like to know more about our information
practiees,please write us at the address shown above.
MUGC9173 0314
CALCULATING THE PREMIUM
The premium amounts in the table below are per$1,000 of coverage. Calculate your annual and/or semiannual premium
in the calculation worksheet,following the steps and example below.
To calculate annual and semiannual premium:
1) Divide your desired death benefit amount by 1,000.
2) Locate your age group and gender on the table below to identify the premium rate per thousand.
3) Multiply#1 by#2 above.
4) Add$36 for the annual policy fee to obtain the annual premium for the coverage.
5) Multiply the annual premium by.52 to obtain the sexniannual premium for the coverage.
's n�a z r'"^ ha�� � ,r n � �r;r
i �i. '.`;` .r� �."
0-4 �6.80
$6.10
5-9 $7.70
$6.90
10-14 $8.80 $7.80
15-19 $10.00
$9.00
20-24 $17.00
$12.50
25-29 $21.00
$15.00
30-34 $25.00
$17.50
35-39 $30.00
$20.50
40-44 $35.00
$24.00
45-49 $41.00
$30.00
50-54 $46.00
$33.00
55-59 $58.00
$40.00
60-64 $50.00
$51.00
65-69 $ll 1.00
$72.00
70-74 $154.00
$108.00
�5�79 $196.00
$149.00
80-84 $238.00
$198.00
85 $304.00
$255.00
�xar.lple(Assumes a 50-yea:-old:nale with current group life caverage of$20,OQ0.)
20 X $46.00 = $920.00 + $36 = $956.00
Desired coverage amount/$1,000 Pxemium rate per thousand Premium for coverage Annual oli fee
P �}' Total annual premitun
$956.00 x .52 = $497.12
Tota]annua]premium Total semiannual premium
Calculation Worksheet
X - + $36 - $
Desired coverage amound$I,000 Premium rate per Yhousand Premium for coverage Annual policy fee Total annual premium
x .52 =
Total annual premium Total semiannual premium
Conversion Application
MuTua��`Omax�
This application must be completed and mailed within 31 days after your group insurance ends. Mail the conversion to:
Atm: Group Policy Services,Group Conversion,United of Omaha Life Insurance Company,Mutual of Omaha Plaza,
Nebraska 68175.
LIFE INSURANCE SECTION
1 Applicant's Name (First,Middle,Last) 7 Home Phone Number ( )
8 Amount of Insurance$
2 Social Security Number (Show amount in thousands,not greater than the
amount you are entitled to convert.)
3 Male❑ Female❑ 9 Mode of Premium Payments
❑Annually ❑Semiannually
4 Age 5 Date of Birth 10 Amount Paid with A lication
Mo. Day Yr. PP
6 Residence (Number,Street,City,State,ZIP) $
11 Beneficiary(Give full name and relationship to applicant)
Primary
Contingent
Payment will be shared equally by all primary beneficiaries who survive you;if none,it will be shared equally by all
contingent beneficiaries who survive you. Unless otherwise stated,you have the right to change the beneficiary.
GROUP INFORMATION SECTION
1 Group Policyholder Group Policy No.
2 I have been insured under the above Group Policy as: ❑An employee or member ❑A dependent
3 I became insured under the Group Policy: Month
Day Year
4 My group insurance terminated: Month
Day Year
5 Was termination due to disability? ❑Yes ❑No
(If"Yes,"give date and cause of d�sability.)
LIFE AGREEMENTS SECTION
I am applying to United of Omaha for the life conversion coverage shown above.I agree United will not be under any
obligation or liability under this application unless:
(1) I have the right to convert the insurance shown above.
(2) The application is made within 31 days after my group insurance ends.
Date State signed in
,
ApplicanYs Signature
Whole Life Express Policy Form 6879L-0202, or state equivalent. In OK, 6918L-0202, In OR, 6949L-0202. In TX, 6920L-0202.
135L-0682
INFORMATION TO BE COMPLETED BY THE PERSONNEL OFFICE
Group Policyholder � �y� ��� �=�����r����a��.
Policy No. -�- '� `�
Address (Number,Street,City,State,ZIP)
Applicant's Name �� ���,� .
Certificate No. �:�
1 The Applicant was insured under the above Group Policy as: �An employee or member ❑A dependent
2 For what amount of coverage was the Applicant insured? $ �� ,��;��, �'`@'
3 What is the Applicant's date of birth? '��� Month � Da ����
y �.____Year
4 When did the Applicant become insured under the Group Policy? 6 � Month �
�—Day �.�.—year
5 The Applicant's coverage was: I.�P terminated on � �a Month ��
Day ��B � Year
❑reduced by $ on Month
_Day _ Year
Because of �' � b�4, � .�,:8�,�.,. ��:�
,c,��. :�.
Completed by _ �.g-��,;—}•� � --�J Signature (Employer or Administrator)
Tide ��.�.r�� �� �'�-c� : �� � � "''� -� �'
--r---� � Date ����� �-- , ��.'���"
ARTICLE ll
INJURIE S
Dutv Related Iniurv
An employee who is temporarily disabled in the line of duty shall be permitted to take
compensated leave in addition to workers' compensation benefits for the period of his disability;
however, in no case shall the total amount paid for both workers' compensation and
compensated leave exceed the amount of wages to which the employee would have been entitled
had the injury not occurred, subject, however, to compliance with all of the following conditions:
A. The disability must have resulted from an injury or an illness directly related to or
sustained in the performance of the employee's work The City's determination as to whether the
disability is work related shall be governed by the provisions of Chapter 440, Florida Statutes.
B. The DCR, in his discretion, may utilize the services of a physician to determine
whether an employee claiming a disability is physically and/or mentally able to continue
working or to return to work.
C. The injured employee will remain on workers' compensation status, not to exceed
six hundred (600) hours (nine hundred (900) hours for those on Platoon System). If, as a direct
result of the continuation of the disability involved, the employee is unable to return to work at
the end of this time period, the employee may petition the DCR requesting that the employee be
carried beyond the established time period.
D. The City agrees that any employee injured on the j ob or who suffers a j ob related
illness shall be paid for a full day if his treating physician advises that he could not or should not
return to work.
22
PBA Agreement 10/1/2017 — 9/30/2019 - ADOPTED— 11/13/17
Non-Dutv Related Injurv
In the event the DCR, in consultation with the Police Chief, determines that a non-duty
related disability exists, the following shall apply:
A. If the disability can be corrected, the DCR, in consultation with the Police Chief,
may permit the employee to continue with his normal duties, reassign the employee to other
duties with the Police Department, or temporarily remove the employee from City service.
Should the employee be temporarily removed from City service during the period of time
specified for correction of his disability, the employee may utilize his sick leave, vacation leave
or request a leave of absence without pay for the correction period.
B. If the disability cannot be corrected, the DCR in consultation with the Police
Chief, will attempt to place the employee in another City position, which in DCR's discretion,
the employee can perform satisfactorily. Nothing herein shall require the DCR to create a
position for the employee. If the DCR determines that the employee cannot be placed in another
position, the employee chooses not to accept the position offered, or the DCR in consultation
with the Department Head involved determines that the employee is not satisfactorily performing
in the new position, then the employee shall be afforded an opportunity to resign thereby
retaining any benefits to which he would otherwise be entitled.
23
PBA Agreement 10/1/2017 — 9/30/2019 - ADOPTED— 11/13/17
oRnirv���cF �ra. za��-c�-�i
A1W �R13[C�TAVCE UF TH�?, CIT1�' CQL1l'�+iCIL ��' FIIC�VVATER,
FL[3Rif]A, :��vIENDiIti�� TNi. [,[TY �?F EDGEVVATFit, �LC]RID:�
POL[C� i7�FFIC`ERS' PE�ISI(�N PLAN T� Pi�t�[}VI�� FC}N A FUBLIC
SAFET�' LIP�{E UF DUTY �'`+i,TURY II�SUR?►NCE BE°�i�FIT FCIR P(}LICE
{lFFICF:I�tS; PRf]VIDI��G F[J�R �tF.PEAL OF LAW'S Ci�' C�NFLICT;
PRDti'll)ING Ff)R SEYERABCLITY�; �'RU<<IDINC� F(�lR CQllI�'ICATI�CIh;
�'_tiI� PI�[)V[DING F�R A�i EF�'�;C'TIV'E DATE.
'�'�'HFREAS, Chapter 1 I2 �r�vides far a health insuranre hcnctit for c�rtain public satet_y
employ�ees w�hn bccame permanently� disabled after suttierii�g a catastr�phic inj�ry ��-hilc in fresh
�ursuit; and
tiVH£REAS, the �'ity nf Cd�:e�'ater �rishes te� prt�ti�ide a similar health insurar�ce E�enetit
tn p�-�lice ot�ieers wh� b�c:on-�e �ermancntl�.� di�abl�d c�ue to ar7 injun• irs�Lirrcci in tl�e litte c�f�'��t�..
but who do nat qualify f'c�r � �ienefit undcr C'hapter 11? for a permanei�t disahi litti� that rc�ults
trom a�atastrt�pl�ic injun• suffered whiCe in fresh pursuit; arid
WHERE�►S. the City C:nuncil has re��i��ed. revie�sed. and consid�red an actuarial impact
staten�ent describin�th� actual im�,act Qf the amendments pra��ided for f�erein;
NU�'L', THF:��FC�[�E, I3E IT ClRD.AiNED �Y' THF�: C'[Tlr' C[]LINCIL [}F THE
CITY OF EDGEI�'�'ATr�t FI.�R�i"l.A,TH.�T:
Sectian l, Scctic�n �.a4 is herehv �reatec� and shall read as fnl�otiti�s:
Section S,Q�—Lin+e-of-Ilutr4• Ynjur-y� Health lnsurance �3enefit.
{a} F:l�grhilydy�. The City ai Ed�e«�ater shall et�ntini�e hcalth in�urance co4'ea'a2e far
anti� Po�ice ()iticer rti•hn has f'rve or ni�re ��ears �F credited service unr�er th� Citd�
t�f E;dgewater Police Of°ti�ers' Pensio� Fund, and wh«, on or aft�r .lanuaryr 1.
1995, sutfers an injury in the line c7r duty chat wauEd qualifti� hirrr �r her for a
Ser�ice Incurrec� Disahilit�� ti��ithin th� mcaning of sectian w.a� af [his Plan. �
Pulice Of'ticer w�h� �uffers a catas#rnphic injuryF l�°hile in fresh pursuit w•ithin the
meaning �f` �ettir�n 112.19{h}, Flc�rida Statutes, shall not be �ntitled ta the
1
�;;�,4�ihr�,n-�—R.��passages are d�let�ct.
C:nderlined passages are�dded.
#?01�-U-21 -CLE�►fY
�
�eneiit cjes�rihed in thi� sGctic�n �.�:F4 �+ut instead shall k�e entitle+� t� t}�e bcnetit
described in sectinn 7 l?.]9(h}, 1�'lc�rida �+tatutes. "['his ben�ft shala �p�ly onlir to
an injun� that occurred ti�hile on duty and w�hile the Palice Oftic�r is actin�
within thc sc�pc of�mpia��ment. The Police Ufticer shall n�t be eli�ible for this
�enetit for an injury sustained in connectinn with any ur�la��ful a�.ts e�r any
activ�ities not relat4d to a lal� enfnr��in�nt assignment. �:lieibility for this henefit
shall �e deterrr�ined [�y#he I3oard t�f l�r�istccs. l:li�ihilit� shall cease if the Board
e�f Trustees tinds t�iat th� Police [?ffcer receivin� a disa�iility retirement is no
1on�er di��hl�cd, in w�hich c��ent the �3nard of Trustees shall rn�tify the Gitti'.
Eligibilit}� shall cease ��vhen a disahled �'nlice Officer rea�hes a�e 65. If aiter
reach�alg a�e 65 a disahled Pc�lice Offi�er is nr�t eli�ible lor Social 5ecurit��
benetits under 42 LI.S.C. � =�0� or �?3. tlie Citv shall pro��ide supplemental
insurance c�r prer�ium reim�tirsements in a manner equi4�alent to thase benetits
that the I'c�lice Ot�#ic�r �����uld have received if he �r she were eligible f�r 5�cia1
Securit�� hen�#its. An�� tact c�r circumstanee that would dis�ualify� a Police
Qfficcr frazn receiiing a hcnetit under sectian 5.[)3 c�f t�e T'lan sha[1 like.�-ise
disqualif�� thc Policc C7�fticcr frnm rcceivin� a �ienefit unr�er this secti�n �.�74.
(b) f�rraour��. The healtl� insurance prati�ided und�r this s�etion S.f�4 shall �e equal tfl
tha� coveraee as pra�ided ta the t,aty�s current acti��e emplc�yees ar�d mati• �rnl��
be amended if such plan is arnended fnr a1l current �:I�7�lIi7t�ees c�r as c�theru ise
am�.nda[�le in a�cmrdance �ti�ith this section.
(r1 Offset.s. Health insurance ben�tits c�r reimbursenlLnts payabie tram anr�= pr�li�y.
plan, settlen�ent,jud�ment, pri��at� flr �uhlic b4n�.tit, �.��orker`s cc�mpens�tic�ri. �r
any other sflurce shall reduce t11e �cnetits payab�e under this section.
(d] Fx�uud. It is unldtivtul t�r a p�rson to willfull�� and knowingly ma�e. c�r cause tca
b� rnac�e, ar to assist. �anspir� w�ith. or urgt another t� make, c�r cause Cc� be
rnad�, an�� f'als�, fi�au�lulent, c�r misleading c�ra� or w-ritten statement to obtain
this health insurance c�v�ra�e, ln additian tt� an�° a��licable �riminal p�nalt��,
up�n �:c}nviction ic�r a vic�latian as descrihcd in this suhsection {r�}, a Poli�e
�f�icer c�r o�lzer b�netrciar`� ti�°ho re�ei��cs or seeks to re�eive health insurance
benefits under this seetic�n shall forfcit the ri�ht tU receive such health insuran�e
renetits �nd shall reirnburse thL C it�° fc�r all ben�fits �aid due to the fraud or
other prohibited acti�•it�. Fc�r purpases of this su�sectic�n. `"con�°ictic�n" means a
detzrminati�iil ol� �uilt Chat is the r�sult of a plea ar trial. regardtess whether
adjudication is uithheld.
�
PART i3. If an�� se�tian, subsectit�n, �lause. phrase. scntence ar pc�rtion af� this
Orciinance is lar any reason declared br° a c�urt ot competent jurisdi�tion t� be im�alid, such
�
:M;�-:,.�,.,.,,,.�. U.
��passa��s arc �ett .
Underlined passa;es are adc�e�_
#TO1^-(}-21 -C�.EAN
decisian shall be deexx�ed a separate. distinct and indepenc�ent pra�ision and such hc�ldan� shall
not alTect the �alic£ity of tlle remaining portions here�af:
P�tRT C. .F'�lI sec.tinns or �att-�s ��f secli�ns af the Cod� of Or�inances, aIl c�rdinances
i�r �a.rt� t�t r�rdinancts. aa�d a1! re:�E�lu�inns or parts at�resofi�tinns. in contlict here4tith, be and thc
sarr�e, are herebtir rc�eale� ta the ex�ent of such �c�ntlict.
PAftT D. It is the intention c�i�tlie �City Council that th� prc�r�rEsions cat Fhis C7rc�inance
s�iall be came and hc mad� a part c�i'the Cc7de nf()rdinances of�d�ewater, Florid�. and that the
sectians flf this ❑rdir�ancc n�a�' be r�numhered ar re�ettered and the u�ard "Ordinanct'' may b4
�han�ed ta "C°hapter.°' `'�ectian," "Article." nr such ather apprapriate vv�rd or plirase, Ehe use c�f
wtiiell st�all accompl�sh lh� intention her�in cxpressed.
PART E. EFFEC"�`I�v'F, ❑�TE.
This Ordinance shall tal�e pla�e upon �dnptinn.
C'AC-�T F. �DOPTI(lI�.
Af'ter 1�Tatian to approve b}� C ouncilman Blazi a�id Secnnd �y t'ouncil���oman V��t_ thz
vot� on first readin� �f�this ordinance �-hich ��as he[d on ���ay 1, 2017 r��as as falln�'s:
AYE N.AI�'
Mayor h�ike I�nasial: X
�auncilw-�man C'hristine No�-er X
Coti�ncilw•oinan�°Un�� ��o�t �
Councilman �an Blazi �
Councilrnan Gary Ccrnroy� �
-,
�
c�r.L•n�,�,r^„��, ��ssa4€s are delet�d.
[►nderlincd passa�es are adc�e�.
#201'-L7-21 -CLEAN
�'�tter Mr�tian t� d�prove k�y� `��..�.v��F`r-r^.�.�--.. �.�-� �t an:�
rt
.,�'c. � ,
S�conc� by �—c:.=.'_:~�•��y���M� �;.. , the��ote on sect�nd
�
r�adin�lpu�lic hearing c�t thi5 ardinance «-hich tivas fie[d Un.
�cm..�.:-z.::; . ,`�� , 7�117 d�as as foll��vs.
,�
A�'E �iAY
I�Zavor ll�ike Ignasiak ` -
Cr�un�ilw�«man �'hristine Pawer '�,,;
Councilw�rtlan Arnir 1�'o�t ``'�
Councilman L]an gl�?i ``
Caut�cilman CT�ry Conre�y �'�,
PASSED �RI3 1)L�L�r' ai)OPTEU thic •� �,�,� dav of
�
�...�-�. . ��1?.
ATTEST: CIT�' CC�L]NC�i�. QF T�IE
CITY (��' EI)G�'��'�"�TF;R, FLt7R[[)A
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r:.1�,,,�;�:��,_�C.� I$} f.: f�,, ,�C� c--- r�..,� CT
Rahin L. 11�Iatusick� i�7ike Igz�asia�,
Cit�� C'lerklParale�al �r7��-�r
F«z the use and r�liance on�y by the City of Ld�e4�ater, .Apprr�ved �y°the C'ity Cc�ur�cil of the Citti nf Ed�zwater,
F�nri�Ea. �.ppra�ed as ro forrn and I�;aiity bti': � Florida cturin�� the C'it�� Cauncil meecin� held on
r�.aron �Z. 1�1'p�fe. C-s�uir�: this �j'f"� da�' r�f e,�.Tn�; . ?01? under
City AtFesrnev .4�;enda Item i?$ r'� .
I)c�ran.5irns 1�'elte.&Ciaccltct�i �
�
�";L-��=passa�es are dzleted.
t!nderlin�c�passages are added.
#Z017-Q-21 -CLE�►N