Summary Plan Description

Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

ELIGIBILITY AND EFFECTIVE DATES OF COVERAGE

A. WHO IS ELIGIBLE FOR COVERAGE?
As an Active Employee of an Employer for whom Contributions are being paid into the Local 805 Welfare Fund pursuant to a Collective Bargaining Agreement or other written agreement, you and your Eligible Dependent(s) are eligible to participate in the Fund.

It is important that you retain records of your work performed (such as your pay stubs) for Contributing Employers as evidence of your eligibility for Plan coverage. Please be advised that, in the event of a dispute regarding whether work performed constituted work for a Contributing Employer for which Plan coverage is available, you bear the burden of proving that such work was for a Contributing Employer. The Trustees reserve the right to determine whether submitted evidence is adequate to prove service was performed for a Contributing Employer.

B. WHO ARE YOUR ELIGIBLE DEPENDENTS?
Your Eligible Dependents are:

Your legal spouse;
Your unmarried dependent child (ren) under age 19
Your unmarried dependent child(ren) age 19 or over who is/are: (1) attending an accredited college, university, or high school as a full-time student; and (2) chiefly dependent upon you for support. Such child(ren) will continue to be eligible until they are no longer full-time students or until their 23rd birthday, whichever occurs first. You must provide the Fund Office with proof of your child's full-time student status for each semester in order for your child(ren) to be eligible for benefits under this paragraph. Acceptable form of proof is a letter for the semester from the school registrar indicating that the child is a full-time student. "Full-time student" is defined as enrolled for at least twelve (12) credits per semester.
Your unmarried child(ren) of any age who would otherwise lose coverage because of the Plan's age limitations who are incapable of self support due to a physical handicap, developmental disability, mental retardation or mental Illness, provided that the child becomes so incapable prior to age 19, and who is dependent on you for support as of the date on which coverage would otherwise end. You must provide written proof of your child's handicap within 31 days after the date that coverage for the child would normally end. Coverage under the Plan may be continued for as long as the incapacity and dependency continue, subject to periodic review by the Fund, but, in any event, will terminate no later than the date on which your coverage terminates.

For purposes of this section, the term "child(ren)" includes:

Your biological and/or legally adopted child(ren);
Your stepchild(ren) – A stepchild is the natural child or adopted child of your legal spouse, who resides with you and is chiefly dependent on you for support;
A child who has been placed with you for adoption (from time of placement) , for whom you assumed a legal obligation for total or partial support of the child in anticipation of adoption;
A child for whom you are the legal guardian and for whom you are required to provide support, who is chiefly dependent upon you for support;
A child for whom you are required to provide health coverage pursuant to a Qualified Medical Child Support Order (QMSCO). If you have questions about QMCSOs or think you may have received one, contact the Fund Office. All QMCSOs must be submitted to the Fund Office for review and approval.

Individuals eligible for coverage as Employees will also be covered as an Eligible Dependent if they meet the eligibility rules as an Eligible Dependent of another Active Employee (such as when both husband and wife are Active Employees).

It is the Participant’s and Eligible Dependent’s responsibility to complete an affidavit of dependent status and their portion of the dependent student certification application to avoid a lapse in the Dependent student’s coverage. It is also the Participant’s and Eligible Dependent’s responsibility to have the Dependent Student Certification Application completed by the school, college or university and submitted to the Fund Office to provide continuous coverage. This certification will have to be completed at the beginning of every semester or school enrollment period to avoid a lapse in the Dependent student’s health coverage. If the Dependent is not a full-time student, it is the Participant’s or the Dependent’s responsibility to notify the Fund Office within 60 days to obtain COBRA continuation coverage. (See the COBRA and COBRA Notice Procedures sections of this SPD).

i. Qualified Medical Child Support Order (QMCSO)
The Plan will provide coverage for your otherwise eligible children pursuant to a QMCSO. Upon receipt of a medical child support order, the Plan will notify you and each child named in the order of the Plan’s procedures for determining whether the order is qualified. If there is a state administrative agency order rather that a court order, the state administrative agency order must be issued through an administrative process established by state law and must have the force and effect of law under the applicable state law. A copy of the Plan’s procedures with respect to QMCSOs is available, free of charge, upon written request to the Fund Office.

THE PROPER DOCUMENTS VERIFYING YOUR DEPENDENT’S STATUS SUCH AS MARRIAGE LICENSED, BIRTH CERTIFICATES, COLLEGE ENROLLMENT LETTERS AND ALL OTHER NECESSARY DOCUMENTS MUST BE SUBMITTED TO THE FUND. THESE DOCUMENTS MUST BE ON FILE WITH THE FUND BEFORE ANY CLAIMS FOR DEPENDENTS WILL BE PAID.

C. WHEN DO BENEFITS BEGIN?
Generally, Hospital, Major Medical and Prescription benefits begin on the first day of the month following the Fund’s receipt of two (2) months of Contributions on your behalf. The exact date depends on the date that Contributions are required to be paid on your behalf by your Employer as set forth in the Collective Bargaining Agreement between the Union and your Employer. If your Employer fails to commence making Contributions on your behalf when required under the Collective Bargaining Agreement, you will be granted eligibility retroactive to the date the Fund actually receives such Contributions from your Employer on your behalf.

Coverage for your Eligible Dependent(s) will begin on the date you become eligible for coverage or on the date you acquire an Eligible Dependent, whichever occurs later.

i. Enrollment Forms
All Participants must complete an enrollment form obtained from their Employer or the Fund Office. At the time of enrollment, the following copies must be submitted along with your enrollment form: Social Security Card(s) for yourself and all covered dependents, copies of your marriage certificate and birth certificates for your eligible dependent child(ren). In a case where the Fund needs to verify that your dependent is, in fact, dependent on you for support, such as step-children, a copy of the first page of the most recent IRS form 1040 must be submitted. No claims will be paid until the appropriate documents are provided to the Fund Office. If you provide the Fund Office with any false or misleading information, this will constitute fraud and the Board of Trustees reserves the right to terminate the Fund coverage for you and your Eligible Dependents.

SOCIAL SECURITY NUMBERS

Each Eligible Dependent enrolled in the Plan must file with the Plan a copy of a Social Security Card issued by the Social Security Administration to such Eligible Dependent. If your child does not have a Social Security Card, you must obtain one and submit it to the Plan. The Plan will allow a period of six months from the original date of the Participant’s eligibility to secure the Social Security Card for your Eligible Dependent. After that date, the Plan will hold all claims for that Eligible Dependent until the copy of the Social Security Card is received.

ii. Changes to Report
After your coverage becomes effective, it is necessary to notify the Fund Office of any changes in your dependents which occur because of marriage, birth, adoption or placement for adoption. If you are adding dependents, be sure to indicate their dates of birth, social security number and relationship.

In addition, within 60 days of the date of any of the following events, a participant or dependent must inform the Fund Office in writing. These events are: a death, divorce or legal separation, or child losing dependent status under the Plan. You will be held responsible for the full amount paid by the Fund to, or on behalf of, such individual(s) who has(ve) lost dependent status. In addition, failure to notify the Fund Office will constitute fraud and the Board of Trustees reserves the right to terminate the Fund coverage for you (and your remaining dependents, if any).

D. WHEN DO BENEFITS END?
If your eligibility cannot be continued under any of the Welfare Plan provisions, your coverage in the Plan will terminate and the coverage of your dependents will terminate at the same time.

i. Employee Coverage Termination
Your coverage in the Plan will terminate:

if you change jobs and you no longer work for an Employer;
if your Employer fails to pay the required contributions for 90 or more days;
failure to otherwise meet the disability or other eligibility requirements set forth in the Plan;

if the Plan is terminated;
on the last day of the month for which COBRA continuation premiums have been paid to the Fund;
at the end of the COBRA continuation coverage period (assuming that you have duly elected and paid the COBRA premium);
when inducted into the military (unless you have duly elected continuation coverage under USERRA and paid the applicable premiums);
at the end of an approved FMLA leave if you do not return to Covered Employment at the end of the leave;
if you do not provide the Plan with any required information or reports;
if you engage in any fraudulent conduct with respect to the Plan.

ii. Dependent Coverage Termination
The coverage of all dependents will terminate:

when your coverage terminates;
if the Plan is terminated;
on the last day of the month for which COBRA continuation premiums have been paid;
at the end of the allowed COBRA continuation coverage period.

In addition to the reasons listed for termination of dependents’ benefits, your Spouse’s coverage will terminate:

on the last day of the month six months after the entry of an interlocutory decree or upon entry of a final decree of divorce or legal separation, which ever is sooner;
on the last day of the month for which COBRA continuation premiums have been paid;
at the end of the allowed COBRA continuation coverage period.

In addition to the reasons listed for termination of dependents’ benefits, your dependent children’s coverage will terminate:

on the last day of the month of their 19th birthday;
on the last day of the month when they are no longer registered, full-time students at an accredited school or college (i.e., 12 or more credits) or on the last day of the month of their 23rd birthday, whichever occurs first;
on the last day of the month for which COBRA continuation premiums have been paid;
at the end of the allowed COBRA continuation coverage period;
when they marry or otherwise are no longer your dependents; or
upon entering the military.

E. IMPORTANT NOTE
The rules described above with respect to termination of coverage are subject to the sections below discussing FMLA, USERRA and COBRA.

Coverage for your eligible dependents ceases when your coverage ceases, or when they are no longer eligible, whichever occurs first. However, you and your dependents may be entitled to continue coverage on a self-pay basis subject to certain restrictions for a limited period of time. See COBRA Continuation of Coverage, page 20.