Page 6 - PWH 2018 Plan Documents
P. 6
Voluntary Term Life
Elect One: This Benefit Program (employee coverage only)
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:
• Principal Group Policy – Life and AD&D Insurance
• Principal Group Booklet – Certificate for Members
Claims Fiduciary: Principal Life Insurance Company
Claims Administrator: Principal Life Insurance Company
Benefit Program Year: January 1st through December 31st
List all Employers whose Employees participate in this Benefit
Program: Positrol Workholding
Group Term Life
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
