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 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 PLAN ADMINISTRATOR: Louisiana Conference of United Methodist Church 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 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 1. If you are fully insured through Blue Cross, file a grievance with Blue Cross by mail, fax, or email. Section 1557 Coordinator P. O. Box 98012 Baton Rouge, LA 70898-9012 000-000-0000 or 0-000-000-0000 (TTY 711) Fax: 000-000-0000 Email: Xxxxxxx0000Xxxxxxxxxxx@xxxxxx.xxx 2. If your employer owns your health plan and Blue Cross administers the plan, contact your employer or your company’s Human Resources Department. To determine if your plan is fully insured by Blue Cross or owned by your employer, go to xxx.xxxxxx.xxx/xxxxxxxxxxx.

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 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 PLAN ADMINISTRATOR: Louisiana Conference of United Methodist Church 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 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 Planthe 1. If you are fully insured through Blue Cross, file a grievance with Blue Cross by mail, fax, or email. Section 1557 Coordinator P. O. Box 98012 Baton Rouge, LA 70898-9012 000-000-0000 or 0-000-000-0000 (TTY 711) Fax: 000-000-0000 Email: Xxxxxxx0000Xxxxxxxxxxx@xxxxxx.xxx 2. If your employer owns your health plan and Blue Cross administers the plan, contact your employer or your company’s Human Resources Department. To determine if your plan is fully insured by Blue Cross or owned by your employer, go to xxx.xxxxxx.xxx/xxxxxxxxxxx.

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 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 PLAN ADMINISTRATOR: Louisiana Conference of United Methodist Church 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 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 Planthe 1. If you are fully insured through Blue Cross, file a grievance with Blue Cross by mail, fax, or email. Section 1557 Coordinator P. O. Box 98012 Baton Rouge, LA 70898-9012 000-000-0000 or 0-000-000-0000 (TTY 711) Fax: 000-000-0000 Email: Xxxxxxx0000Xxxxxxxxxxx@xxxxxx.xxx 2. If your employer owns your health plan and Blue Cross administers the plan, contact your employer or your company’s Human Resources Department. To determine if your plan is fully insured by Blue Cross or owned by your employer, go to xxx.xxxxxx.xxx/xxxxxxxxxxx.

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 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 PLAN ADMINISTRATOR: Louisiana Conference of United Methodist Church 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 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 Planthe 1. If you are fully insured through Blue Cross, file a grievance with Blue Cross by mail, fax, or email. Section 1557 Coordinator P. O. Box 98012 Baton Rouge, LA 70898-9012 000-000-0000 or 0-000-000-0000 (TTY 711) Fax: 000-000-0000 Email: Xxxxxxx0000Xxxxxxxxxxx@xxxxxx.xxx 2. If your employer owns your health plan and Blue Cross administers the plan, contact your employer or your company’s Human Resources Department. To determine if your plan is fully insured by Blue Cross or owned by your employer, go to xxx.xxxxxx.xxx/xxxxxxxxxxx.

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 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 PLAN ADMINISTRATOR: Louisiana Conference of United Methodist Church 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 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 1. If you are fully insured through Blue Cross, file a grievance with Blue Cross by mail, fax, or email. Section 1557 Coordinator P. O. Box 98012 Baton Rouge, LA 70898-9012 000-000-0000 or 0-000-000-0000 (TTY 711) Fax: 000-000-0000 Email: Xxxxxxx0000Xxxxxxxxxxx@xxxxxx.xxx 2. If your employer owns your health plan and Blue Cross administers the plan, contact your employer or your company’s Human Resources Department. To determine if your plan is fully insured by Blue Cross or owned by your employer, go to xxx.xxxxxx.xxx/xxxxxxxxxxx.