Page 3 - PWH 2018 Plan Documents

The documents that govern the operation and administration of the Cafeteria Plan
Arrangement include:

Plan Document
Summary Plan Description

Benefit Program Year: January 1st through December 31st

List all Employers whose Employees participate in the Cafeteria Plan
Arrangement: Positrol Workholding

III. The Health Benefit Programs listed below are group health plans offered
under the Plan:

Check all that apply. Identify and list documents as applicable.

Medical

Elect One: This Benefit Program will be offered under the
Cafeteria Plan Arrangement; OR

This Benefit Program will not be offered under
the Cafeteria Plan Arrangement (or the Cafeteria
Plan Arrangement does not apply).

The documents that govern the operation and administration of the Benefit
Program include:

• Anthem Certificate of Coverage
• Anthem Summary of Benefits and Coverage (SBC)
Claims Fiduciary: Anthem
Claims Administrator: Anthem
Benefit Program Year: January 1st through December 31st
List all Employers whose Employees participate in this Health Benefit Program:
Positrol Workholding

Health Reimbursement Arrangement (HRA)

Elect One: This Benefit Program will be offered under the
Cafeteria Plan Arrangement; OR

This Benefit Program will not be offered under
the Cafeteria Plan Arrangement (or the Cafeteria
Plan Arrangement does not apply).

The documents that govern the operation and administration of the Benefit
Program include:

• Custom Design Benefit Group Contract