SR-603-007 (2)
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6"2-0
9-/1
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~03-0(} r
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CONFIDENTIAL
PE:SEM:p
Santa Monica, Californla
TO:
Mayor and Clty CouneLl
FROM:
Clty Staff
SUBJECT:
Resolutlon Authorlzlng Amendment
Understandlng WIth The
AssOcIates/MunIcIpal Employees
AuthoriZIng ApplIcatIon for State
Coverage
To The Memorandum of
Supervisory Team
'"i>..SSDC:.Lol.. .i.vu aud
DIsabllIty Insurance
IntroductIon
Thls report requests that CounCIl adopt the attached Resolution
authorIzing the CIty Manager to execute an amendment to the
Memorandum of UnderstandIng between the City and the Supervlsory
Team AssocIates/MunIcIpal Employees ASSOClatIon (STA) In order to
provlde State DlsabIlIty Insurance (SOl) coverage and authorlzlng
the Mayor to make the necessary applicatIon for said coverage.
Background
In 1982 the CIty and STA entered lnta an MOU that will expIre on
December 31, 1984.
SInce a representation electIon must be held
prIor to the commencement of negotlatlons and that electIon lS
scheduled for January 3, 1985, no successor agreement wi th STA
wlll be reached by December 31, 1984.
State Dlsability Insurance
coverage has been requested by STA as a benefit under any
successor agreement that may ultimately be negotIated.
The statute WhICh authorlzes applIcatIon for SOl coverage on a
bargalnIng unIt by bargalnIng unit baSIS expIres on December 3l,
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1984. Unless the City applIes for coverage for STA by that date
the coverage they desire WIll not be avaIlable.
Although the applIcatIon must be made by December 31, 1984,
coverage can be effectIve at any tIme next year.
STA has agreed
to a March 1, 1985 start date to provide tIme for sucessor
agreement negot ia tions.
The questIon of whether the City WIll
pay for the benefIt will be resolved In those negotIations.
SInce the Sta te requI res that coverage result from an executed
agreement, staff has prepared a proposed amendment to the current
MOU. STA will ratIfy the amendment Thursday, December 13, 1984.
FInanCIal/Budgetary Impact
The SOl rate effectIve January 1984 IS .6% of payroll.
If, as a
result of negotiatIons, the CIty, rather than the employee pays
for SOl coverage, the cost would not exceed $7,000 for the
remaInder of the fIscal year and provISIon for that amount could
be made In the mId-year budget adJustments, If necessary.
RecommendatIon
Staff recommends that Council adopt the attached Resolution
authorIzing the City Manager to execute the attached amendment to
the Memorandum of UnderstandIng with the SuperVIsory Team
AssocIates/MunIcIpal
Employees
ASsocIatIon
.
and
authorIZIng
the
Mayor to execute the necessary applIcatIon for SOl coverage,
subject to STA ratIfIcatIon of the amendment.
Prepared By: Susan E. McCarthy, Director of Personnel
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RESOLUTION NO. 6956(CCS}
(CITY COUNCIL SERIES)
A RESOLUTION OF THE CITY COUNCIL OF
THE CITY OF SANTA MONICA AUTHORIZING THE
/'
CITY MANAGER TO EXECUTE AN AMENDMENT TO THE MEMORANDUM
OF UNDERSTANDING WITH THE SUPERVISORY TEAM ASSOCIATES/
MUNICIPAL EMPLOYEES ASSOCIATION (STA)
'"
AND AUTHORIZING THE MAYOR TO EXECUTE AN APPLICATION
FOR COVERAGE UNDER SECTION 710.5 OF THE UNEMPLOYMENT
INSURANCE CODE ON BEHALF OF STA
WHEREAS, the CalifornIa Unemployment Insurance Code permits
publ ic agency employers to elect coverage for dlsablll ty
insurance only, wIth respect to all employees in an appropriate
unlt as established by law as a result of a negotlated agreement;
and
WHEREAS, the SUPERVISORY
EMPLOYEES ASSOCIATION and the Cl ty
TEAM
ASSOCIATES/MUNICIPAL
have met and conferred and
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.
agreed to amend the Memorandum of UnderstandIng between the
partIes to provide such coverage effectIve March 1, 1985;
NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF SANTA
MONICA DOES RESOLVE AS FOLLOWS:
/'
SECTION 1: The CIty Manager IS hereby authorIzed to execute
the attached amendment to the Memorandum of UnderstandIng between
the
CIty
of
Santa
Monica
and
the
SuperVIsory
Team
AssocIates/MunICIpal Employees ASSOCIatIon provided that the
amendment IS ratified by STA on Thursday, December 13, 1984.
..
SECTION 2: ElectIon of coverage under SectIon 710.5 of the
Unemployment Insurance Code IS approved and the Mayor is hereby
authorIzed to execute the attached applicatIon on behalf of the
Supervisory Team ASSOCIates/MunIcIpal Employees ASSOCIatIon wIth
the Employment Development Department of the State of CalIfornIa
prOVIded that the above referenced amendment is duly ratified.
SECTION 3: The CIty Clerk shall certify to the adoption of
thIS ResolutIon and thenceforth and thereafter the same shall be
in full force and effect.
APPROVED AS TO FORM:
'.
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ROBERT M. MYERS
City Attorney
- 2 -
- -. " o~ C'T -d.,"_T \
, . S J....& - J: .u....L~ u:-...., J...
" E~h6y:~\'"T DEVr:LOP~~:'IT DEP~'.:~T
800 CAPITOL ~~\LL
SACW.J::;:-O, CALIFOR;aA 95814
-,,:::::--~
'Y-
'\.-
For VeDart~~r.t Use ~ly
Ap?lic~ticn for Elective Coverage of Disability Insurauc~
Only for Errployees of a Public Sc~ool EIT?loyer uncer Sectio~
710.4 or a Public Agency E~loyer u~der Section 710.5 of the
Cal~forn~a Unenploy~ent Insurance Code
Accm....' t iio.
Statistical Code
Effective I:;ate
Classified By
Date .
E~ployer ~o~ified
(da.te)
Send
N~~ber of Ecployees
IMPORTANT
/~This fo~ is not an ap?l~cation for an acco~t nu~ber under the cOili?u1so~. p~ovlsior.s 0= the
UneL?loyr.ent Insurance Code. Do not conplete this form unless you wish to apply :or D~saDil:ty
Insurance coverage m;LY under Sect::..ons 710.4 or 710.5 for your enployees. Coverage l1ncer thl'se
sec~iO~5 of the Code does not ~ake provis~on for Unenployren~ l~surance bene:~~s.
RO~L: If your~ap?11cation is approved) the elect~ve coverage agree~e~t will be subject to
all of the requirere>J.ts and conditio",,5 outlined in for"":l. DE 1378 p. "Info~~tion
Concerning Elective Coverage Under Sect10ns 710.4 or 710.5 of the Ur.e~?lcy~ent Insura~ce
Code.n Please retain your copy of fOr:l DE 1378 ? for reference.
*******~~*********
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1. Na~e of Employer
City of Santa Mon~ca
Please Type or Print
213-458-8246
La~ under ,;h~ch agency was-e&tablished (Co~?lete e~ther (a), {b), (c) or (d).)
(~) Ca11:ornia General Laws
Title of Act NUTIbe~ Year Enacted
(b) California CodeS
-Title of Code
Sect~o~s to
2.
Ih:sir.ess Address' 1685 Ma~n Street
(Street and !;uc;)e=)
}"Jailing Actress Same
(Street a.'1.d !;\;::'De~)
~y?e of Public ZT.ployer (Check one)
Dpublic School - Section 710.4
~uDlic: Agency - Section 7JO.5
4.
(c) Charter
Title Charter of c~ ty of S .r-1.
(d) Ordina.-:.ce
Title
6. Me~~ers of Gove~~lnG body of the e~?10yer.
Nal:'!':!
Chr~stlne Reed
_ltlm. Jennlngs
(Tcl~"hone)
Santa Monica CA . 90;JOl
( C~ ty ) (County) (Star.e) (Z:.? ~ ,
l..ouej
(CHY) (CoU:l:Y) (St2C:~) (',., - CC:.Jc)
L....I.-r.
Nur.:.bC!.r
,
Chap:::.:.:"
Part
Date
Date
Nu.,be~
Tir:~2
ReSlc~rce A~(rp~s
B~':J L..:Srd St. S:i'!. ~O-lO}
9100 Wllshlre Blvd. LA
Hayor
~ayor Pro Tempore
James Conn
Ken Ed'::vards
_David Ensteln
Herbert Katz
--.Dennls Zane
CounclH1ember
CounclU":ember
CounciH!ember
Councl1i'lember
CouncllHember
235 Hlll St~, S.M. 90~05
42H 15th St., S.M. 90405
8601 Wllshlre Blvd. I LA902
2209 Pearl St. ,--S.H. 904crs-
1685 ~aln St., S.M. 90401
DE 1378 ~ Rev. 3 ell-eO)
(Pas~ 1 of 2)
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7.
Th~s application covers eMployees of the following units:
Na~e of De?art~ent or Unit
Addrec;s
~uperv~sory Team Assoc~ates
1685 Y-ain St., Santa Mon~ca
90401
8. Co~plete this schedule covering all elected officers and appo~ntees who ?erform serv~ces
for the agency na~ed in Item 1. Exclude persons listed in Iten 6.
(a) Elected offices:
Title of Position
(These persons are ineligible for coverage.)
N /1\
(b) Person holding appointive positions: (These persons are eligi~le for coverage
unless appointed to fill a vacant elected office.) .'
Title of Positic~
No. of Positions
in tris Cate~orv
.. .
~y t~hon A??ointed
N~~e= of Suc~ Persc~s
Des~~~n~ CoveraQe
..
Spe AttachmEi;!nt
. .
.
(c) Total nunber of e=2:oyees to be covered (excl~ding elected officers and these
appoi~~ed by the Governor).
9.
On what date do you wish coverage to beco~ effective?
r,1arch 1, 1985
",
,
a
Deductions shoulG not be nade frQn your ecplcyeest wages for the purpose of payir-g
e~?loyee contributions requi~ed unde~ the Code-until your election is effect~ve.
A~tach a CO?y of the resolution in "lhich the gove-rnirLg body described in Itan 6 ap?roved
the filing of an ap~licat~on for elective coverage unce~-Section 7r6.4 or 710.5 of the IT.-
er::?loyro:ent Insu:::'a~ce Coce" Also, a copy of the Barg<:ining AgreeTI'ent bet~,-een tr.e e=71cyer
and the certified e~?loyee or6~nization.
***~~~*~~*~*****~***
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TIw 6overn~.ental entity described in Item I hereby f~les its applic::tion under Sect~on 710.4 or
710 5 of the Une::,?loyrrent Inst:r.:lnce Coce to beco:-oe an en:ployer subj ect to tbe Code. It is ur:ceI
sta Ie thar: upon appro'.Tal of thE. election by the Di=2ctor, the Public Scl'ccl!?L~11c Ase~c:. E:'1-
plc'e= ~ill be an e~plcyer subJect to t~e Code for D~sab~11ty Insura~ce pu~o5es cnlv to the
sac ~ exte...t oS other ec.?loyers as of the date spcc:d'icG in the app~oval. np-a tolll re~~it', 3.
sub ect err,;.:1loyer for at leas::: t-....o COI:;>l..:=te calend",~ ),ears and there.:.iter, uatil th15 ele;:tio:,
is [:ercinated as Froviced Dy the Code.
I d.:clar.?: ::.bat this applic<it:.a~ haS beer. eY..m::.l.::.eJ by mc. dnd to :::he best of n:y knowledsc ane.
be:~e:, it is true and correct and wade in Eood faIth under the prGvis~ons of the Cdl~fornia
GnWl? loyo:-ent Insurance Coca.
v(Si~ne~--k.-e. k--~ D~te I L' I?-. 8i
(Siti~ed) Date
Th ~ c!ec.l.::rc"!t_ic:1 ~t.!st be ~~~r'ec b.... cn~
or ,:lOre persons sr:a",JIl l;nder I;:e-- 6.
(Signed)
Date
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AGREEMENT AMENDING
MEMORANDUM OF UNDERSTANDING
./
THIS AGREEMENT entered lnto thls 14th day of December,
1984 by and between the CITY OF SANTA MONICA, a munlclpal
corporat ion (hereInafter tlCI tylt) and the SUPERVI SORY TEAM
ASSOCIATES/MUNICIPAL EMPLOYEES ASSOCIATION (hereInafter "STAIt),
is made wIth reference to the following:
R E C I TAL S
~
A. The CIty and STA entered into a memorandum oE
understandIng 10 July 1982, entltled nMemorandum of Understanding
Between CI ty of Santa Monlca, Cal i fornia and Superv isory Team
ASSOCIates/MunICIpal Employees Association" (hereInafter ItMOUIt).
B. It is the mutual desire of CIty and STA to amend saId
MOO to make proviSIon for coverage under Section 710.5 of the
Unemployment Insurance Code (State DIsablll ty Insurance) to be
effective March 3, 1985.
NOW, THEREFORE, it is mutually agreed by and between the
CIty and STA as follows:
1. On and after December 14, 1984, Section 44 "State
DIsability Insurance" is added to the MOU to read as follows:
Pr10r to December 31, 1984, the CIty shall make applIcatIon
for State DIsabilIty Insurance coverage on behalf of
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.
.
employees covered herein, under Section 710.5 of the
Unemployment Insurance Code.
I f coverage IS approved by
the State of Ca1 i fornIa, it shall be effecti ve March 3,
1985.
/"
2. Except as expressly mod 1 f led hereIn, all other terms
and covenants set forth In the MOU shall remaIn the same and
shall be In full force and effect.
IN WITNESS WHEREOF, the parties hereto have caused thI s
agreement to be executed on the day and year first above wrItten.
~
~CITY OF SANTA MONICA
.
~/~.
JO~I
City Manager
APPROVED AS TO FORM:
~~. \-0
ROBERT M. MYERS
CIty Attorney
SUPERVISORY TEAM ASSOCIATES/
MUNICIPAL EMPLOYEES ASSOCIATION
\'\. ~ \
K\JJ~J'\
Robert Harvey
~{l...~
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.
1i;tU~ n..L~
WlllJ..am Jlas /~ry
1; -
/1 ~d e ijJ.ljJ~/ ~
Jlcilt Jones
~.
1
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I
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AGo~ted and approved thIS 11th day o( December, 1984.
C4-k~ ~-
/ Mayor
I hereby certIfy that the foregoing ResolutIon No. 6956(CCS)
was duly adopted by the CIty Council of the CIty of Santa MonIca
at a meetu1g thereof held on December 11, 1984 by the followIng
CouncIl vote:
Ayes: Councllmembers: Conn, Edwards, EpsteIn, JennIngs,
Katz, Zane and Mayor Reed
Noes: Councllmembers: None
AbstaIn: Councllmembers: None
Absent: Councllmembers: None
ATTEST:
{2L-v1 1/' ~~~
CIty Clerk
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VOTE: AffIrmatIve:
~egatIve:
AbstaIn:
Absent'
PROOF VOTES WITH ANOTHER PERSO~ BEFORE A~~THING
Dl SIRI jjjjT I O:-J' . ORI GINAi. LO De signed, -seaied ana
'_ -t.
.
BEFORE JISTRIBUTION CHECK CONTENT OF ALL
DISTRIBUTION OF RESOLUTION # ~ 7?s-~
CouncIl MeetIng Date .,/d/IIIIY
q--~-ST,If--
~<<o
7- 0
Agenda Item t;
Was It amended?
.
FOR CITY C~ERK'S ACTION
ORDINAt'lCE #
Introduced:
Adopted:
All"lAYS PUBLISH AOOPT.till ORDINANCES *
*Cross out Attorney's approval
...:,
filed in Vault.
NEWSPAPER PUBLICATION (Date:
)
)
Department orIgInating staff report (
Management Serv.~ces Lynne Ba~rette--urdinances only
~
Agency mentIoned In document or staff report
(cert1. fied?)
Subject flle (agenda packet) 1
Others-
Counter fIle 1
Airport
Parking Auth.
.-'\udl torum
Personnel
B-J.lldlng Dept
Planning
EnVl ron. Ser\T.
Police (en-
forcement?)
FInance
Purchasing
FIre
Recr/Parks
General Servo
Transportation
Llbrary
Treasurer
Manager
SE~D FOU~ COPIES OF ALL ORDINA~CES TO:
CODpD SYSTH1S ~ At tn pe"ter Maci-ear ie
120 Maln <:::ty,=,et
AV0~, ~ew Jersev_07717
-- , .
SEl':D FOUR COPIES OF AU. ORDTNANrp"<;;; to:
PRESIDI1\'G JUDGE
SA~TA MO~ICA MU~ICIPAL COURT
1 72;) l.1AIN STREET
SA~TA MONICAJ CA 90401
I
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*Check COde Sections before send1ng.
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TOTAL COPIES
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AGREEMENT AMENDING
MEMORANDUM OF UNDERSTANDING
THIS AGREEMENT entered into thIS
day of December,
1984 by and between the CITY OF SANTA MONICA, a mun1cIpal
corporation
(hereInafter
"CIty")
and
the SUPERVISORY TEAM
ASSOCIATES/MUNICIPAL EMPLOYEES ASSOCIATION (hereInafter "STA"),
is made wIth reference to the following:
R E C I TAL S
A. The C1ty and STA entered into a memorandum of
understandIng 1n July 1982, entItled "Memorandum of UnderstandIng
Between C1 ty of Santa MonIca, CalIfornIa and SuperVIsory Team
Assoc1ateS/Municlpal Employees ASSocIatIon" (here1nafter "MOU").
B. It IS the mutual desIre of Ci ty and STA to amend saId
MOU to make prOVISIon for coverage under SectIon 710.5 of the
Unemployment Insurance Code (State D1sabIlity Insurance) to be
effective March 3, 1985.
NOW, THEREFORE, 1t 1S mutually agreed by and between the
CIty and STA as follows:
1. On and after December 14, 1984, SectIon 44 "State
D1sabI1Ity Insurance" 1S added to the MOU to read as follows:
Prior to December 31, 1984, the C1ty shall make applicatIon
,
for State Disab111ty Insurance coverage on behalf of
- 1 -
.
.
employees covered hereIn, under Section 710.5 of the
Unemployment Insurance Code.
If coverage is approved by
the State of Call fornia, It shall be effecti ve March 3,
1985.
2. Except as expressly mod 1 fled hereIn, all other terms
and covenants set forth In the MOU shall remaIn the same and
shall be In full force and effect.
IN WITNESS WHEREOF, the parties hereto have caused thl s
agreement to be executed on the day and year fIrst above wrItten.
CITY OF SANTA MONICA
JOHN JALILI
Clty Manager
APPROVED AS TO FORM:
fl.t~ \,N\.. h- - ~
ROBERT M. MYERS 0
Clty Attorney
SUPERVISORY TEAM ASSOCIATES/
MUNICIPAL EMPLOYEES ASSOCIATION
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$1.-,;::::'" Of C:u..i?O~~L\
R-fr'"L GY~ fE:lj .i.. DEVELO?;IDiT DE9?5~3\.F.'~~T
BOJ CA?ITOL ~~L
SAC.WiI~;::O, CALIFO~{lA
For Departre~t Use ~:y
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Ap?lic~~ion for Elective Coverage of Disability Insur~nce
Only for E~ployees of a Public School Err?loyer under Section
710.~ or a Public Agency E~loyer uncer Section 710.5 of the
Ca11forn1a rnenploy~ent Insurance Code
Accoc;nt iIo.
Statistical Code
Effective Date
Classified By
Date
E~?loyer Noti:ied
(cate)
Send
N~~ber of E~ployees
IrTORTANT
/,ThlS form is not an a?p11cation for an acco~t nurr.ber under the co~?u1scry prcv~sions 0: the
Une~~loywent Ins~ra~ce Cece. Do not cOLplete this form unless you wish to ap?ly for Disa~ll:tJ
Insurance coverage ONLY uncer Sections 710.4 or 710.5 for your enp1oyees. Coverage ~Tcer th(se
sect~ou5 of the Code does not make provis~on for Unenploy~ent Insurance bene:~cs.
~OT~: If your~ a?pl~cation is approved) the elect~ve cave~age agree~~~t w~ll be s~~Ject to
all of the requirerents and cond~tio~s outlined in for":l DE 1378 p) "Inforr.atl.on
Concerr.ing Elective Coverage Under Sections 710.4 or 710.5 of the Une~?loyment Insura,ce
Coce.u Please retain your copy of fom DC 1378 P for reference.
*******~**~*******
Please Type or Pr~nt
1. Kar.e of E~ployer
Clty of Santa Monlca
213-458-8246
2.
Bcsi:::.ess Address
1685 Maln Street
(Street and KU~De~)
Same
Santa r.lonlca
(Gay) (COU1,ty)
CA
(1:e:..;..e;:Jf1.0ne)
- 90401
(5::5:.:e) (Z.:.;)
n . ,
'-'CG2j
'3.
Y.al.ling Address
(Street a."'l.t: ::uw~e:L)
4. ~y?e o~ ?ub~~c Z~ployer (Check one)
o r\..oEc Scheol - Section 710.4
[}g>P~blic. Agency - Section no.s
(CJ..ty)
(Cot:.ili:y)
(Stc.~e)
(Zlp CC:.Je.)
-t
L~"'~ 5.
-,
Law under ~lh~ch agency was,estnblished (Co~plete 21tner (2), {b). (c) or Cd).)
(a) Califorr.la General LawS
Title of Act NtiI!1oer Year Enacted
. .
(b) Califo~n~a COGas
- Title of Code
Sect~o4s Co
Nuruber
Part
Chap~er
f . (c) Charter
Title Charter of Clty of S .H.
(d) Ordir.a..-: C2
Title
Date
Date
NU':lber
6. Me~~ers of gove~~~n~ b8dy of the ell~loye~.
Na~'~
.Chrlstlne Reed
VIm. Je:r.~lngs
Ii r:l2
Res~dc:r ce .:\d I,:rc 0:: f
~~~ L3rd St. S.~. ~u~uj
9100 wilshlre Blvd. LA
Hayor
~ayor Pro Tempore
James Conn
Ken Edwards
DaVld EDstein
Herbert Katz
_~ennl s Z ane
Counc 1 H1ember
Counc lli<:erlDer
CounclUlember
Counc l Ulember
CouncllHember
235 Hlll St., S.M. 90405
428 15th St., S.M. 9U40j
8601 Wilshlre Blvd., LA9021
'2209-pearl St., S.H.' 90cll.}Y
1685 ~aln St., S.M. 90401
(Pa;~ 1 of 2.)
DE 1378 ~ Rev. ] (ll-gO)
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7.
Th~s application covers erployees of the follo~ing un~ts:
Na~e of ~oart1-ent or Luft
Address
Supervlsory Team ASSoClates
1685 ~ain St., Santa Nonlca 90401
8. Cowplete this schedule covering all electeu officers and appo1ntees who ?erfor~ services
for the agency na~ed 10 Ite~ 1. Exclude persons listed in Iten 6.
(a) Elected offices:
Title of Posi~ion
(These persons are ineligible for coverage.)
J:ljA
(b) Person holding appointive positions: (These persons are e1igi~le fo~ coverage
unless appoiLited to fill a vacant elected office.)
Tit~e of Posit~on
No. of Positions
in t~is Cate~o~!
By t~no~ A?point2d
N~b2~ of SUC~ ?ersc~s
D2s::.-::~r.z Covera2e ~
s,pp Attachment
.
.
(c) Total nc=b~r of eC210yees to be covered (exclcding elected office~5 and those
appointed by the Governor).
9.
On ~hat date do you ~lsh coverage to beco~e effec~ive?
Harch 1, 1985
.,
, 10.
Deduct~ons shoule not be ~ce fron your eEPloyees' wages ror the PU170se cf paying
eu?loyec contributions required under the Code ~~til your electicn is effective.
Attach a CO?y of the resolution in WalCn the governing body Gescribec in IteD 6 ap?~oved
the filing of an ap~l~cat~on for elective coverage unce~ Section 7TO.4 or 710.5 of the In-
er:::.?loyment Insurance Coce. Also~ a copy of the Barg.::lning AgreeI:'ent bet~.-een tt.e e:::ployer
and the certif~eci e~?loyee organization.
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The governrr.ental entity cescri~ed in Ite~ 1 hereby riles its appljc~t~on uncer Sec~lon 71J.4 or
7105 of the Une=:?loyrent Irs1.:ra.nce Coce to beco;'ie an c1!lployer st:bject to t~e Code. It 15 er::e~-
sm IC t:,at upon ap?rcval of the elccc:.o':1 by the Director, the Pebl:u:: Scl1Ccl/I'l...~l~c Ager.cy EC'-
plo'er ~ill be an e~plcyer st:D)ect to t~e Code for ~~sab~l~~y Ins~~ance p~~cses only to tpe
sac: exter.t C:s oth:::r ecployers as of the. date spec::..ficG in the ap?~oval, ar.d Tn'~ll re;::.::.::.r:. a
SU~ ect e~?loyer for at least ~~O COc?lcte cale~a~~ years and t~erea:ter. u~til t~~s ele~:icn
is ~er=inated as Frov~eed oy tne Co~e.
I d,:clare :::hat this applicatior:. has beer. eY.atl~ed by n:e. dna to the best of "=-'.l knowledi;c a....c.
bel~e:~ it is tr~e ar.d correct and ffi3de in bocd fa~th uncer t~e prov1sions of the Cdl~fornia
Une'~;>loy;nent Insurance Coce.
TI:i. c.ec~:::r2tic.:1 ::'\\:s:: ~e sl.::r~c 1:1.. on~
or :lOre uersons s['o,,:n t.:nder I:::e-' 6.
(Si~nec)
(Si;:;:1cd)
(Signed)
D3.t.e
Date
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