Common use of GENERAL PLAN INFORMATION Clause in Contracts

GENERAL PLAN INFORMATION. NAME OF PLAN: Louisiana Conference of United Methodist Church NAME AND ADDRESS OF EMPLOYER/PLAN SPONSOR: Louisiana Conference of United Methodist Church 00000 Xxxxx Xxxx. Baton Rouge, LA 70802 EMPLOYER IDENTIFICATION 00-0000000 NUMBER (EIN): PLAN NUMBER (PN): 501 TYPE OF PLAN: Dental Benefit Plan FUNDING MEDIUM AND TYPE OF ADMINISTRATION: The Plan is a self-funded Group Dental Plan. Benefits are administered on behalf of the Plan Administrator, by Blue Cross and Blue Shield of Louisiana, pursuant to the terms of the Administrative Services Agreement and the terms and conditions of the Plan. The funding for the Benefits is derived from the trust of the Employer and contributions made by covered Employees. Employee contributions are at a rate determined by the Plan Sponsor. The Plan is not insured. PLAN ADMINISTRATOR: Louisiana Conference of United Methodist Church 000 Xxxxx Xxxx. Baton Rouge, LA 70802 225-346-1646 AGENT FOR SERVICE OF Service for legal process may be made upon the Plan LEGAL PROCESS: Administrator or if applicable, a Plan Trustee. CLAIMS ADMINISTRATOR: United Concordia Dental (UCD) PO Box 69420 Harrisburg, PA 17106-9420 0-000-000-0000 PLAN YEAR ENDS: December 31st PLAN DETAILS: The eligibility requirements, termination provisions and a description of the circumstances which may result in disqualification, ineligibility, denial, or loss of any benefits are described in the Benefit Plan. FUTURE OF THE PLAN: Although the Plan Sponsor expects and intends to continue the Plan indefinitely, the Plan Sponsor reserves the right to modify, amend, suspend, or terminate the Plan at any time. Blue Cross and Blue Shield of Louisiana HMO Louisiana Southern National Life Nondiscrimination Notice Discrimination is Against the Law Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc., does not exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex in its health programs or activities. Blue Cross and Blue Shield of Louisiana and its subsidiaries: • Provide free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (audio, accessible electronic formats) • Provide free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, you can call the Customer Service number on the back of your ID card or email XxxxxxxxxxXxxxxxXxxxxxxxXxxxxxxxxxx@xxxxxx.xxx. If you are hearing impaired call 0-000-000-0000 (TTY 711). If you believe that Blue Cross, one of its subsidiaries or your employer-insured health plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you have the right to take the following steps;

GENERAL PLAN INFORMATION. NAME OF PLAN: Louisiana Conference of United Methodist Church NAME AND ADDRESS OF EMPLOYER/PLAN SPONSOR: Louisiana Conference of United Methodist Church 00000 Xxxxx Xxxx. Baton Rouge, LA 70802 EMPLOYER IDENTIFICATION 00-0000000 NUMBER (EIN): 00-0000000 PLAN NUMBER (PN): 501 TYPE OF PLAN: Dental Benefit Plan FUNDING MEDIUM AND TYPE OF ADMINISTRATION: The Plan is a self-funded Group Dental Plan. Benefits are administered on behalf of the Plan Administrator, by Blue Cross and Blue Shield of Louisiana, pursuant to the terms of the Administrative Services Agreement and the terms and conditions of the Benefit Plan. The funding for the Benefits is derived from the trust of the Employer and contributions made by covered Employees. Employee contributions are at a rate determined by the Plan Sponsor. The Plan is not insured. PLAN ADMINISTRATOR: Louisiana Conference of United Methodist Church 000 Xxxxx Xxxx. Baton Rouge, LA 70802 225-346-1646 AGENT FOR SERVICE OF LEGAL PROCESS: Service for legal process may be made upon the Plan LEGAL PROCESS: Administrator or if applicable, a Plan Trustee. CLAIMS ADMINISTRATOR: United Concordia Dental (UCD) PO Box 69420 Harrisburg, PA 17106-9420 0-000-000-0000 PLAN YEAR ENDS: December 31st PLAN DETAILS: The eligibility requirements, termination provisions and a description of the circumstances which may result in disqualification, ineligibility, denial, or loss of any benefits are described in the Benefit Plan. FUTURE OF THE PLAN: Although the Plan Sponsor expects and intends to continue the Plan indefinitely, the Plan Sponsor reserves the right to modify, amend, suspend, or terminate the Plan at any time. Blue Cross and Blue Shield of Louisiana HMO Louisiana Southern National Life Nondiscrimination Notice Discrimination is Against the Law Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc., does not exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex in its health programs or activities. Blue Cross and Blue Shield of Louisiana and its subsidiaries: • Provide free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (audio, accessible electronic formats) • Provide free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, you can call the Customer Service number on the back of your ID card or email XxxxxxxxxxXxxxxxXxxxxxxxXxxxxxxxxxx@xxxxxx.xxx. If you are hearing impaired call 0-000-000-0000 (TTY 711). If you believe that Blue Cross, one of its subsidiaries or your employer-insured health plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you have the right to take the following steps;

GENERAL PLAN INFORMATION. NAME OF PLAN: Louisiana Conference of United Methodist Church NAME AND ADDRESS OF EMPLOYER/PLAN SPONSOR: Louisiana Conference of United Methodist Church 00000 Xxxxx Xxxx. Baton Rouge, LA 70802 EMPLOYER IDENTIFICATION 00-0000000 NUMBER (EIN): 00-0000000 PLAN NUMBER (PN): 501 TYPE OF PLAN: Dental Benefit Plan FUNDING MEDIUM AND TYPE OF ADMINISTRATION: The Plan is a self-funded Group Dental Plan. Benefits are administered on behalf of the Plan Administrator, by Blue Cross and Blue Shield of Louisiana, pursuant to the terms of the Administrative Services Agreement and the terms and conditions of the Benefit Plan. The funding for the Benefits is derived from the trust of the Employer and contributions made by covered Employees. Employee contributions are at a rate determined by the Plan Sponsor. The Plan is not insured. PLAN ADMINISTRATOR: Louisiana Conference of United Methodist Church 000 Xxxxx Xxxx. Baton Rouge, LA 70802 225-346225/346-1646 AGENT FOR SERVICE OF LEGAL PROCESS: Service for legal process may be made upon the Plan LEGAL PROCESS: Administrator or if applicable, a Plan Trustee. CLAIMS ADMINISTRATOR: United Concordia Dental (UCD) PO Box 69420 Harrisburg, PA 17106-9420 0-000-000-0000 PLAN YEAR ENDS: December 31st PLAN DETAILS: The eligibility requirements, termination provisions and a description of the circumstances which may result in disqualification, ineligibility, denial, or loss of any benefits are described in the Benefit Plan. FUTURE OF THE PLAN: Although the Plan Sponsor expects and intends to continue the Plan indefinitely, the Plan Sponsor reserves the right to modify, amend, suspend, or terminate the Plan at any time. Blue Cross and Blue Shield of Louisiana HMO Louisiana Southern National Life Nondiscrimination Notice Discrimination is Against the Law Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc., does not exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex in its health programs or activities. Blue Cross and Blue Shield of Louisiana and its subsidiaries: • Provide free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (audio, accessible electronic formats) • Provide free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, you can call the Customer Service number on the back of your ID card or email XxxxxxxxxxXxxxxxXxxxxxxxXxxxxxxxxxx@xxxxxx.xxx. If you are hearing impaired call 0-000-000-0000 (TTY 711). If you believe that Blue Cross, one of its subsidiaries or your employer-insured health plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you have the right to take the following steps;