Page 42 - Allied_Plan Doc SPD 0101214

APPENDIX A

BENEFIT PROGRAMS OFFERED: MEDICAL/PRESCRIPTION DRUG, DENTAL, VISION, SHORT-TERM DISABILITY
INSURANCE COVERAGE, LONG-TERM DISABILITY INSURANCE COVERAGE, GROUP TERM LIFE INSURANCE,
ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE COVERAGE.
BENEFIT PROGRAM/ NAME OF INSURER/ POLICY OR CLAIMS
BENEFITS
EFFECTIVE DATE CLAIMS CONTRACT PROVIDED ELIGIBILITY PROCEDURE
OF COVERAGE ADMINISTRATOR NUMBER(S) & BENEFITS
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP MEDICAL BLUE CROSS BLUE 007005570/00 and Certificates and Certificates and Certificates
INSURANCE SHIELD OF 00 of Insurance and of Insurance and of Insurance
MICHIGAN other benefit other benefit and other
benefit
materials
materials
HDHP w/ HSA provided by provided by materials
INSURER/CLAIMS Insurer. Insurer. provided by
ADMINISTRATOR
01/01/2013 Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP MEDICAL BLUE CARE 00126332/000 and Certificates and Certificates and Certificates
INSURANCE NETWORK OF 1/0001 of Insurance and of Insurance and of Insurance
MICHIGAN other benefit other benefit and other
materials
materials
benefit
HMO provided by provided by materials
INSURER/CLAIMS Insurer. Insurer. provided by
ADMINISTRATOR
01/01/2013 Insurer.
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP DENTAL GUARDIAN LIFE 00468295 and Certificates and Certificates and Certificates
INSURANCE INSURANCE of Insurance and of Insurance and of Insurance
COMPANY OF other benefit other benefit and other
AMERICA materials materials benefit
01/01/2013 provided by provided by materials

Insurer. Insurer. provided by
INSURER/CLAIMS Insurer.
ADMINISTRATOR
See Plan/SPD See Plan/SPD See Plan/SPD
GROUP VISION GUARDIAN LIFE 00468295 and Certificates and Certificates and Certificates
BENEFITS INSURANCE of Insurance and of Insurance and of Insurance
COMPANY OF other benefit other benefit and other
AMERICA materials materials benefit
01/01/2013 provided by provided by materials

Insurer. Insurer. provided by
INSURER/CLAIMS Insurer.
ADMINISTRATOR

See Plan/SPD See Plan/SPD See Plan/SPD
SHORT-TERM LINCOLN FINANCIAL 01-0104800 and Certificates and Certificates and Certificates
DISABILITY BENEFITS GROUP (LINCOLN of Insurance and of Insurance and of Insurance
NATIONAL LIFE) other benefit other benefit and other
materials
materials
benefit
01/01/2013 provided by provided by materials
INSURER/CLAIMS Insurer. Insurer. provided by
ADMINISTRATOR Insurer.

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