CCR1996223WisconsinDeFartmentQfEmployeTrustFunds SOLUTIO^^ j1223-96
A RESOLUTION FOR INCLUSION UNDER GROUP LIFE INSURANCE
RESOLVED, by the Common Council ofthe City of Muskego
(Governlng !jooy) (tmployer Legal Name1
that pursuant to Ihe provisions Of Chapter 40 of the Wsconsin Statutes suchcornon COUnC i.1 hereby determines to be
Included
under the followtng group lhfe Insurance program(s) provided by Chapter 40 of the Wisconsin Statutes for its eliglble personnel:
(Governing Body)
Check box(es) for coverage desired:
Basic Group Life Insurance
Supplemental Group Life Insurance
Additionai Group Life Insurance
Spouse and Dependent Group Llfe Insurance
on or afler the effective date Of this resolution shall be 50%
rather than 25%
Amount of insurance far any insured employe who attains age 65
BE IT FURTHER RESOLVED. that lhe proper officers are herewith authorized and directed to take all actions and make such
deductions and submit such payments as are required by the Group Insurance Board of Ihe Slate of Wisconsin to provide such group life
insurance. I
BE IT FURTAER RESOLVED, that the City of Muskego WRS Agent submit a certified copy Of this
resolution to the State of Wisconsin Department of Employe Trust Funds.
(Empioyer Name)
CERTIFICATION
I hereby certify that the foregoing resolution is a true, correm and complete copy of the resolution duly and reguiarly passed by the
of Muskego on thedxlday of Sep t . ,
-J
(Governmg Uooy) (tmpioyer Name)
19% and that said resolution has not been repealed or amended. and is now in full force and effect Dated thtsa day of "&a& f A
19 96.
I understand that Wisconsin Statutes. s. 943.395, provide criminal penalties for knowlngly making false and fraudulent statements on
ths form and hereby certlty that. to the best of my knowledge and
Employer Identification Number (EIN) 65-036- 1194-000
Agent Signsture Tlrie
W182 S8200 Racine Avenue
Muskego, WI 53150
Mailing Address
TelephoneNumber (414 \ 679-5624
Number of eligible employes: 30
The resotut1on shall be effective on the 1st of the 4th month afler receipt in the ofice of the Department of Employe Trust Funds
RECONSIDERED & AMENDED
AT 9/26/96 SPECIAL COUNCIL
MEETING
ET-1303 (REV 4/93)