Page 25 - 15NH Intertek
P. 25
Intertek U.S.A.
If You Have Questions Women’s Health and Cancer Rights Notice
Questions concerning your Plan or your Intertek Employee Health Care Plan is required by law to provide you with the
COBRA continuation coverage rights should following notice:
be addressed to the contact or contacts
identiied below. For more information The Women’s Health and Cancer Rights Act of 1998 (“WHCRA”) provides certain
about your rights under the Employee protections for individuals receiving mastectomy-related beneits. Coverage will be
Retirement Income Security Act (ERISA), provided in a manner determined in consultation with the attending physician and
including COBRA, the Patient Protection the patient for:
and Affordable Care Act, and other laws X All stages of reconstruction of the breast on which the mastectomy was
affecting group health plans, contact the performed
nearest Regional or District Ofice of the X Surgery and reconstruction of the other breast to produce a symmetrical
U.S. Department of Labor’s Employee appearance
Beneits Security Administration (EBSA)
in your area or visit www.dol.gov/ebsa. X Prostheses
(addresses and phone numbers of Regional X Treatment of physical complications of the mastectomy, including
and District EBSA Ofices are available lymphedemas
through EBSA’s website.) For more
information about the Marketplace, visit The Intertek Employee Health Care Plan provide(s) medical coverage for
www.HealthCare.gov. mastectomies and the related procedures listed above, subject to the same
deductibles and coinsurance applicable to other medical and surgical beneits
Keep Your Plan Informed of provided under this plan.
Address Changes
To protect your family’s rights, let the Plan If you would like more information on WHCRA beneits, please refer to your
Administrator know about any changes Summary Plan Description or contact your Plan Administrator.
in the addresses of family members. You Revised October 19, 2010
should also keep a copy, for your records,
of any notices you send to the Plan
Administrator.
Plan Contact Information
Heather Schuerman
2 Riverway, Suite 500
Houston, TX 77056
(713) 543-3777
OMB Control Number 1210-0123 (expires
10/31/2016)
© 2015 Lockton, Inc. All rights reserved.
Images © 2015 Thinkstock. All rights reserved.
[Rev 03/03/15] EB\INTER08\EE Comm\New Hire\15NH.pdf 25
If You Have Questions Women’s Health and Cancer Rights Notice
Questions concerning your Plan or your Intertek Employee Health Care Plan is required by law to provide you with the
COBRA continuation coverage rights should following notice:
be addressed to the contact or contacts
identiied below. For more information The Women’s Health and Cancer Rights Act of 1998 (“WHCRA”) provides certain
about your rights under the Employee protections for individuals receiving mastectomy-related beneits. Coverage will be
Retirement Income Security Act (ERISA), provided in a manner determined in consultation with the attending physician and
including COBRA, the Patient Protection the patient for:
and Affordable Care Act, and other laws X All stages of reconstruction of the breast on which the mastectomy was
affecting group health plans, contact the performed
nearest Regional or District Ofice of the X Surgery and reconstruction of the other breast to produce a symmetrical
U.S. Department of Labor’s Employee appearance
Beneits Security Administration (EBSA)
in your area or visit www.dol.gov/ebsa. X Prostheses
(addresses and phone numbers of Regional X Treatment of physical complications of the mastectomy, including
and District EBSA Ofices are available lymphedemas
through EBSA’s website.) For more
information about the Marketplace, visit The Intertek Employee Health Care Plan provide(s) medical coverage for
www.HealthCare.gov. mastectomies and the related procedures listed above, subject to the same
deductibles and coinsurance applicable to other medical and surgical beneits
Keep Your Plan Informed of provided under this plan.
Address Changes
To protect your family’s rights, let the Plan If you would like more information on WHCRA beneits, please refer to your
Administrator know about any changes Summary Plan Description or contact your Plan Administrator.
in the addresses of family members. You Revised October 19, 2010
should also keep a copy, for your records,
of any notices you send to the Plan
Administrator.
Plan Contact Information
Heather Schuerman
2 Riverway, Suite 500
Houston, TX 77056
(713) 543-3777
OMB Control Number 1210-0123 (expires
10/31/2016)
© 2015 Lockton, Inc. All rights reserved.
Images © 2015 Thinkstock. All rights reserved.
[Rev 03/03/15] EB\INTER08\EE Comm\New Hire\15NH.pdf 25
