Fill and Sign the Summary Plan Description Checklist Form

Summary Plan Description Checklist In addition to the plan’s benefits, eligibility for benefits, and the plan’s limitations, a Summary Plan Description must contain the following information: Official name of the plan; Name, address, and phone number of the plan sponsor/plan administrator; Employer Identification Number; Plan number; Type of welfare plan; Type of administration of the plan; Name and address of the insurer(s), health service organization(s), or third party organization(s) responsible for the financing or administration of the plan; Name of person designated as agent for service of legal process, address at which process may be served, and a statement that service of legal process may also be made upon a plan trustee (as applicable) or the plan administrator; Description of relevant provisions of any collective bargaining agreement (as applicable); Source of contributions to the plan; Source of plan financing; Date of the end of the plan year, and whether plan records are kept on calendar, policy or fiscal year basis; Additional Provisions 1. Qualified medical child support order procedure (or a statement indication where a participant can obtain a copy of a procedure at no charge; 2. A complete Statement of COBRA Rights and Duties; 3. Statement of ERISA Rights; 4. Notice of Rights under the Mothers and Newborns Health Protection Act; 5. Provider Network listing (where applicable) (or a statement indicating where a participant can obtain c a copy of the current list at no charge); 6. Statement of Procedure for termination amending the Plan or eliminating benefits as well as a statement of participant’s rights in the event of Plan termination or amendment or elimination of benefits; and, 7. Claims and Appeals Procedure in sufficient detail to meet the requirements of the 11/21/00 Regulation (or attachment of a copy of a separately written claims and appeal procedure.Additional Summary of Material Modification Requirement (For Plan Years Beginning on or after July 1, 1997) If there is a modification or change that is a material reduction in covered services or benefits provided under a group health plan, a summary description of such modification or change shall be furnished to participants and beneficiaries not later than 60 days after the date of the adoption of the modification or change. In the alternative, the plan sponsors may provide such description at regular intervals of no more than 90 days.