Page 41 - HarborLight CU 2014-15 SPD
P. 41
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, EMPLOYEE ASSISTANCE PROGRAM AND HEALTH
REIMBURSEMENT ARRANGEMENT.
BENEFIT PROGRAM/ NAME OF INSURER/ POLICY OR BENEFITS ELIGIBILITY CLAIMS
EFFECTIVE DATE CLAIMS CONTRACT PROVIDED PROCEDURE
OF COVERAGE NUMBER(S) & BENEFITS
ADMINISTRATOR
GROUP MEDICAL BLUE CROSS BLUE 007013108/00 See Plan/SPD See Plan/SPD See Plan/SPD
INSURANCE SHIELD OF 01 and Certificates and Certificates and Certificates
CDHP w/ HRA MICHIGAN of Insurance and of Insurance and
09/01/2014 of Insurance
INSURER/CLAIMS other benefit other benefit and other
GROUP DENTAL ADMINISTRATOR materials materials
INSURANCE benefit materials
provided by provided by provided by
09/01/2014 Insurer. Insurer. Insurer.
GROUP VISION
PRINCIPAL 1004572- See Plan/SPD See Plan/SPD See Plan/SPD
BENEFITS FINANCIAL GROUP 10001 and Certificates and Certificates and Certificates
of Insurance and of Insurance and
09/01/2014 INSURER/CLAIMS of Insurance
ADMINISTRATOR other benefit other benefit and other
materials materials
benefit materials
provided by provided by provided by
Insurer. Insurer. Insurer.
VISION SERVICE 12193480 See Plan/SPD See Plan/SPD See Plan/SPD
PLAN (VSP) and Certificates and Certificates and Certificates
of Insurance and of Insurance and
INSURER/CLAIMS of Insurance
ADMINISTRATOR other benefit other benefit and other
materials materials
benefit materials
provided by provided by provided by
Insurer. Insurer. Insurer.
GROUP TERM LIFE SUN LIFE FINANCIAL 021-1365-2 See Plan/SPD See Plan/SPD See Plan/SPD
INSURANCE and Certificates and Certificates and Certificates
BENEFITS INSURER/CLAIMS of Insurance and of Insurance and
ADMINISTRATOR of Insurance
other benefit other benefit and other
materials materials
benefit materials
provided by provided by provided by
Insurer. Insurer. Insurer.
09/01/2014
ACCIDENTAL DEATH SUN LIFE FINANCIAL 021-1365-2 See Plan/SPD See Plan/SPD See Plan/SPD
AND and Certificates and Certificates and Certificates
INSURER/CLAIMS of Insurance and of Insurance and
DISMEMBERMENT ADMINISTRATOR of Insurance
INSURANCE other benefit other benefit and other
COVERAGE materials materials
benefit materials
provided by provided by provided by
Insurer. Insurer. Insurer.
09/01/2014
36
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, EMPLOYEE ASSISTANCE PROGRAM AND HEALTH
REIMBURSEMENT ARRANGEMENT.
BENEFIT PROGRAM/ NAME OF INSURER/ POLICY OR BENEFITS ELIGIBILITY CLAIMS
EFFECTIVE DATE CLAIMS CONTRACT PROVIDED PROCEDURE
OF COVERAGE NUMBER(S) & BENEFITS
ADMINISTRATOR
GROUP MEDICAL BLUE CROSS BLUE 007013108/00 See Plan/SPD See Plan/SPD See Plan/SPD
INSURANCE SHIELD OF 01 and Certificates and Certificates and Certificates
CDHP w/ HRA MICHIGAN of Insurance and of Insurance and
09/01/2014 of Insurance
INSURER/CLAIMS other benefit other benefit and other
GROUP DENTAL ADMINISTRATOR materials materials
INSURANCE benefit materials
provided by provided by provided by
09/01/2014 Insurer. Insurer. Insurer.
GROUP VISION
PRINCIPAL 1004572- See Plan/SPD See Plan/SPD See Plan/SPD
BENEFITS FINANCIAL GROUP 10001 and Certificates and Certificates and Certificates
of Insurance and of Insurance and
09/01/2014 INSURER/CLAIMS of Insurance
ADMINISTRATOR other benefit other benefit and other
materials materials
benefit materials
provided by provided by provided by
Insurer. Insurer. Insurer.
VISION SERVICE 12193480 See Plan/SPD See Plan/SPD See Plan/SPD
PLAN (VSP) and Certificates and Certificates and Certificates
of Insurance and of Insurance and
INSURER/CLAIMS of Insurance
ADMINISTRATOR other benefit other benefit and other
materials materials
benefit materials
provided by provided by provided by
Insurer. Insurer. Insurer.
GROUP TERM LIFE SUN LIFE FINANCIAL 021-1365-2 See Plan/SPD See Plan/SPD See Plan/SPD
INSURANCE and Certificates and Certificates and Certificates
BENEFITS INSURER/CLAIMS of Insurance and of Insurance and
ADMINISTRATOR of Insurance
other benefit other benefit and other
materials materials
benefit materials
provided by provided by provided by
Insurer. Insurer. Insurer.
09/01/2014
ACCIDENTAL DEATH SUN LIFE FINANCIAL 021-1365-2 See Plan/SPD See Plan/SPD See Plan/SPD
AND and Certificates and Certificates and Certificates
INSURER/CLAIMS of Insurance and of Insurance and
DISMEMBERMENT ADMINISTRATOR of Insurance
INSURANCE other benefit other benefit and other
COVERAGE materials materials
benefit materials
provided by provided by provided by
Insurer. Insurer. Insurer.
09/01/2014
36
