Summary Plan Description

Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

GENERAL INFORMATION

Name of Plan	Local 805 Welfare Fund
Plan Sponsor	Board of Trustees Local 805 Welfare Fund 44-61 11th St. 3rd Floor Long Island City, NY 11101
Employer Identification Number (EIN) assigned by IRS	13-1620897
Plan Year	February 1 – January 31
Plan Number	501
Type of Plan	This welfare plan provides Hospital, surgical, major medical, dental, optical, prescription drug and life insurance benefits.
Type of Administration	This plan is jointly administered by the Board of Trustees made up of equal representatives of union and management.
Plan Administrator	Board of Trustees Local 805 Welfare Fund 44-61 11th St. 3rd Floor Long Island City, NY 11101 (718) 609-6401
Agent for Service of Legal Process	Neal S. Schelberg, Esq. Proskauer Rose, LLP 1585 Broadway New York, NY 10036 James S. Frank, Esq. Epstein Becker & Green, PC 250 Park Avenue New York, New York 10177-1211 Service of legal process may be made upon a plan trustee or the Plan Administrator
Sources of Contributions	Contributions are made by employers pursuant to collective bargaining agreements or other written agreements requiring that such Contributions be made. Contributions may also be made by individuals who continue their coverage under the COBRA provisions of the Plan.
Collective Bargaining Agreements	The plan is maintained pursuant to collective bargaining agreements between participating employers and the Union between participating employers and the Fund. A copy of any such agreement may be obtained by participants and beneficiaries upon written request to the Plan Administrator, and is available for examination by participants and beneficiaries. A complete list of the employers and employee organizations sponsoring the plan may be obtained by participants and beneficiaries upon written request to the Plan Administrator and is available for examination by participants and beneficiaries. In addition, participants and beneficiaries may receive from the Plan Administrator, upon written request, information as to whether a particular employer or employee organization is a sponsor of the Plan, and if so, the sponsor’s address.
Administration	The Hospitalization and Major Medical benefits of the Plan are administered by the Local 805 Welfare Fund. The Fund utilizes GHI for the purpose of adjudicating and making payments of medical claims. The dental benefits of the Plan are administered by HealthPlex, 60 Charles Lindbergh Boulevard, Uniondale, NY 11553. HealthPlex is responsible for the administration and payment of dental benefits. The prescription drug benefits of the Plan are administered by Express Scripts PO BOX 66583, St Louis, MO 66583. Express Scripts is responsible for the administration and payment of prescription drug benefits. All other benefits are self-insured by the Local 805 Welfare Fund. The Fund is responsible for the payment of all claims covered by this Plan.