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Health Plan Tier (Per Month) City <br />Contribution <br />to Premium <br />City <br />Contribution <br />to *VEBA <br />Single Plans *TBD $130.00 <br />Total Monthly <br />City <br />Contribution <br />*TBD <br />Employee -F Spouse Plans $1007.00 $160.00 $1,167.00 <br />Employee + Children Plans $1.091.00 $160.00 $1,251.00 <br />Family Plans $1,166A0 5192.00 $1,358.00 <br />j <br />* The above listed City VEBA contribution includes a $4.30 per month VEBA <br />administration fee. In 2016, the least expensive single plan (the $4000 deductible <br />plan/Accord network) will be paid in full <br />Or <br />Provide cash in lieu of City's insurance contribution of $370 per month in 2016. <br />Employees receiving the waiving benefit prior to 2013 will continue to be grandfathered <br />in to the waiving benefit. New employees to the program are subject to the following <br />terms: <br />• Employee shows proof' of other coverage, and <br />• Employee agrees to the terms of the waiving benefit as described within the City's <br />policy and signs the acknowledgement form, and <br />Ail other provisions of Article XVllll shall apply normally. <br />FOR THE ,CITY OF <br />BY: <br />Sarah Strommen, Mayor <br />ATTEST: <br />EY: <br />qb01 <br />Date <br />urtis G. Ulrich. City Administrator Date <br />FOR LAW ENFORCEMENT LABOR <br />BY: <br />I3Y: <br />Nicholas I7ahllerg, Srwar41---- <br />A l9—`�" <br />Steward <br />BY:�L <br />Adam Burnside, LELS Date <br />RVICES, INC. <br />Date <br />Date <br />i — Z / J / ✓ <br />21 <br />