SUMMARY PLAN DESCRIPTION
NAME OF PLAN
The Plan for which this Summary Plan Description is provided is known as the I.B.E.W. Local 25 Health & Benefit Plan.
MAINTENANCE OF PLAN
The Plan is maintained by I.B.E.W. Local 25 Heath & Benefit Fund located at 372 Vanderbilt Motor Parkway, Hauppauge, New York, 11788.
EMPLOYER IDENTIFICATION NUMBER AND PLAN NUMBFR
The employer identification number (EIN) assigned by the Internal Revenue Service to the plan sponsor is 11-1630810. The Plan number assigned by the Plan sponsor is 501.
TYPE OF WELFARE PLAN
The Plan is a Plan Participant and Dependents Death Benefit, Medical, Dental, Optical, Hearing, Prescription, Supplemental Unemployment Benefit and Medical Reimbursement Account Plan.
ADMINISTRATION OF PLAN
The Plan is administered by the Board of Trustees of I.B.E.W. Local 25 Health & Benefit Fund.
FUND MANAGER
Name of Fund Manager: | Owen M. Rumelt |
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Address: | 372 Vanderbilt Motor Pkwy. Hauppauge, New York 11788 |
Telephone Number: | (631) 434-3344 |
Fax Number: | (631) 434-3397 |
AGENT FOR SERVICE OF LEGAL PROCESS
The person designated as agent for service of legal process upon the Fund is Archer, Byington, Glennon & Levine, LLP.
The address at which process may be served on such entity is One Huntington Quadrangle, Suite 4C10 Melville, New York 11747. In addition, service of process may be made upon the Fund Manager or any Trustee.
TRUSTEES
The name, title and address of the principal place of business of each Trustee of the Fund are:
EMPLOYER | ADDRESS |
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Steven Cadieux | Roland’s Electric Co., Inc. 307 Suburban Avenue Deer Park, NY 11729 |
Paul Dunn | Mainline Electric Corp 295 Broadway Huntington Station. NY 11746 |
Clifford Seaman | Gordon L. Seaman, Inc. 29 Old Dock Road Yaphank, NY 11980 |
Pat Santoro | Com-Bell Systems 561 Acorn Street, Unit C Deer Park, NY 11729 |
UNION | ADDRESS |
Kevin Casey | Local 25, I.B.E.W. 370 Vanderbilt Motor Pkwy. Hauppauge, NY 11788 |
Godfrey King | Local 25. I.B.E.W. 370 Vanderbilt Motor Pkwy. Hauppauge, NY 11788 |
James P. Malley | Local 25, I.B.E.W. 370 Vanderbilt Motor Pkwy. Hauppauge, NY 11788 |
Sean Plant | Local 25, I.B.E.W. 370 Vanderbilt Motor Pkwy. Hauppauge, NY 11788 |
COLLECTIVE BARGAINING AGREEMENTS
The Plan is maintained pursuant to Local 25, I.B.E.W. Collective Bargaining Agreements. A copy of such agreement(s) may be obtained upon written request to the Fund Manager, who may make a reasonable charge for the copies, and is available for examination by Plan Participants and beneficiaries at the Fund Office.
ELIGIBILITY AND BENEFITS
The Plan’s requirements respecting eligibility for participation, the conditions pertaining to eligibility to receive benefits, and description or summary of the benefits are included in this
booklet.
SOURCES OF PLAN CONTRIBUTIONS
Contributions to the Fund are made by contributing employers and in certain instances by Plan Participants of the Fund.
MEDIUM FOR PROVIDING BENEFITS
Benefits under the Plan are self-insured by the Fund, except for the insured Death Benefits.
DATE OF END OF PLAN’S FISCAL YEAR
The date of the end of each year for purposes of maintaining the Plan’s fiscal records is December 31.
CLAIM PROCEDURES
- Presenting Claims for Benefits:Claim forms may be obtained from:I.B.E.W. Local 25 Health & Benefit Fund
372 Vanderbilt Motor Parkway
Hauppauge, New York 11788
(631) 434-3344
www.eibofli.com
Please see page 52 of this booklet for the requirements as to notice of claims. - Claims Denial Procedure:Any denial of a claim for benefits will be provided by MagnaCare and shall
consist of a written explanation which will include:- Specific reasons for the denial;
- Reference to the pertinent Plan provisions upon which the denial is based;
- A description of any additional information You might be required to provide and explanations of why it is needed; and
- An explanation of the Plan’s claim review procedure.
You, Your beneficiary (when an eligible claimant), or a duly authorized representative may appeal any denial of a claim for benefits by filing a written request for a full and fair review to the Fund. In connection with such a request, documents pertinent to the administration of the Plan may be reviewed, and comments and issues outlining the basis of the appeal may be submitted in writing. You may have representation throughout the review procedure. A request for a review must be filed within 180 days after receipt of the written notice of denial of a claim. The full review will be held and a decision rendered by the Fund, no later than 60 days after receipt of the request for review. If there are any special circumstances, they will be made as soon as possible, but not later than 120 days after the receipt of the request for review. If such an extension of time is needed, You will be notified in writing prior to the beginning of the extension period. The decision after review will be in writing and will include specific reasons for the decision, as well as specific references to the pertinent Plan provisions on which the decision is based.