Page 60 - HarborLight CU 2014-15 SPD

 Response to Parties YES NO

Date letter sent accepting/rejecting QMCSO

Any response from parties?
Date Received

Date referral to legal counsel
Notes on further action:

Steps Taken Pursuant to QMCSO

YES NO

Is there an additional contribution required to extend coverage under the
QMCSO?

Has determination been made that withholding the additional contribution
does not exceed applicable state and federal wage withholding limitations?

Is employee currently enrolled in the Plan?

Date enrollment form issues to employee

Is alternate recipient child currently listed as a dependent on the Plan?

Date alternate recipient child enrolled in Plan

Person to whom it is expected that benefit reimbursements are to be mailed (as

designated by the QMCSO):
Name:

Address:

Phone:

Reimbursements must be made to the individual providing proof of payment for the incurred
expenses. Information identifying the individual to receive payment should be provided to the
claims administrator.

Relationship to alternate recipient child:

Employee Parent Other Parent State Agency Legal Guardian Other

Date alternate recipient child added to mailing list for recipient of all SPDs, SARs, etc?

Person to Whom copies of all notices are to be mailed:

Name:

Address:

Phone:

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