LOCAL UNION NO. 1OF THE CONSTRUCTION WORKERS WELFARE
TRUST FUND
Dear Participant: This booklet summarizes the benefits offered by the Constructions Workers Local No. 1 Health and Welfare Plan. Eligible employees may
choose medical coverage provided by Kaiser or through The Insurance Company. The Plan also provides dental, prescription drug, vision care,
and life insurance benefits. This booklet briefly describes each of these benefits and how to qualify for them. The Trustees of the Plan hope that these benefits will protect you and your family members if any of you suffer illness or injury. They also hope
that you will use your health benefits intelligently, taking advantage of the Preferred Provider discounts and following the rules requiring
pre-certification of hospital stays and other cost containment features. By doing so, you will qualify for maximum benefits. At the same time, you
will help the Plan to provide benefits in the most cost-effective way possible.
Please remember that this booklet is only a summary. In the event of any dispute, the official language of the group insurance policy or other master agreement will be controlling.
Only the full Board of Trustees is authorized to interpret the Plan.
The Board has discretion to decide all questions about the amount of any benefits payable to you. The Board also has discretion to make any factual determinations concerning your claim. No
individual trustee, employee or union representative has authority to interpret this Plan on behalf of the Board or to act as an agent of the Board. All decisions by the Board are final and binding.
The Board has authorized the administrative office to respond in
writing to your written questions. If you have an important question about your benefits, you should write to the administration office for a definitive answer.
As a courtesy to you, the administrative office also may respond informally to oral questions. However, oral information and
answers are not binding upon the Board of Trustees and cannot be relied on in a dispute concerning your benefits. Plan rules and benefits may change from time to time. If this occurs, you will receive a written notice explaining the change. Please be sure to read
all plan communications and keep information about benefit changes with this booklet. Sincerely, The Board of TrusteesTABLE OF CONTENTS [to be inserted] SUMMARY PLAN DESCRIPTION FOR THE EMPLOYEES OF Constructions Workers LOCAL NO.1 HEALTH & WELFARE TRUST The Employee Retirement Income Security Act of 1974 requires that certain information be furnished to each participant (or eligible participant) in the employee benefit plan.
Trustees of Construction Workers Local No.1 Welfare Trust Fund:
c/o Administration Company 5500 Market Street
San Francisco, CA 94000 Fund Identification Number: 12-1234567
This employee benefit plan is administered by the Trustees of the Construction Workers Local No.1 Welfare Trust Fund. Fund Administrator Administration Company 5500 Market Street San Francisco, CA 94000
Telephone: (415) 123-4567 Agent for Service of Legal Processes
Administration Company 5500 Market Street
San Francisco, CA 94000 Telephone: (415) 123-4567 Service of process also may be made upon any plan trustee. Board of Trustees Union Trustees
John Smith 1000 Highrise Street San Francisco, CA 94000 Jack O'Lantern2222 Anywhere Street Concord, CA 94001 Peter Buns3333 Somewhere Street San Leandro, CA 90000 Employer Trustees James Doe4444 Something Street Concord, CA 94001 John Jones5555 Anyone Street Walnut Creek, CA 94002 The relevant provisions of the Collective Bargaining Agreement, the names
of the parties thereof and the expiration date may be reviewed at:
Administration Company 5500 Market Street San Francisco, CA 94000 Disbursement of benefits: The Fund provides coverage through
insurance issued by the Insurance Company. The Fund's fiscal year ends on June 30 each year. This plan may be terminated through collective bargaining, by action of the
Board of Trustees, or by operation of law. In the event of termination any assets remaining after payment of eligible benefit claims and expenses
shall be used for the exclusive purpose of providing continued benefits for eligible participants and beneficiaries or else shall be transferred to a successor plan or plans.
IMPORTANT NOTICE
Your eligibility for benefits depends on the continued and timely payment of employer contributions on your behalf. Even if you work the necessary
hours, your hour bank cannot be credited and coverage cannot be provided unless your employer actually pays the fringe benefit contributions you
have earned. If your employer stops making contributions to the plan, your eligibility for benefits will cease when the coverage actually paid for has
been exhausted. Eligibility will be restored if and when the required contributions are received.
If you are referred to a job through the union office and lose your coverage solely because the employer fails to pay the contributions you have
earned, your coverage will be extended for up to 2 months. This extension will also apply if you have solicited employment with a signatory contractor
and you have called the union office and verified that this contractor is current with its fringe benefit payments and is therefore eligible to employ you under the bargaining agreement. HELP PREVENT WASTE AND FRAUD Every year billions of health care dollars are wasted because of erroneous and even fraudulent claims. Billing errors by hospitals and doctors' offices
are very common. A few dishonest providers intentionally make false statements on bills or claim forms, or omit important information which would cause the claim to be denied. You and your family can help catch billing errors and prevent fraud.
Carefully review your bills and the plan's written explanation of each benefit payment, and immediately report any errors or discrepancies. Respond
promptly if the plan administrator requests your help to verify that a claim is valid. Do not give details about your health coverage to anyone except
your authorized health care providers. Do not sign blank claim forms. Inform the plan if outsiders attempt to obtain billing information or claim forms from you. Your plan takes fraud very seriously. All claims are checked to be sure the patient is eligible and the treatment was received. The trustees require
a full refund of any benefit payment obtained by fraud, with interest and legal costs. Any incident involving fraud may also be referred to the
authorities for criminal prosecution. Attempting to defraud a health plan is a crime under both federal and state laws, even if the fraud is detected and the plan is not actually harmed.
If you observe any activities by health care providers or others which might
indicate fraud, please alert the plan office immediately. The plan will investigate the matter and take whatever action is necessary. If you wish, your report can be entirely confidential.
Your Rights as a Plan Participant.As a participant in the Construction Workers Local No.1 Health and Welfare Trust Fund you are entitled to certain rights and protections under
the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan participants shall be entitled to:
Examine, without charge, at the plan administrator's office and at other specified locations, such as worksites and union halls, all
plan documents, including insurance contracts, collective bargaining agreements and copies of all documents filed by the plan with the U.S, Department of Labor, such as detailed annual reports and plan descriptions.
In addition to creating rights for plan participants, ERISA imposes duties
upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the
plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one including your employer, your
union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your claim for a welfare benefit is
denied in whole or in part you must receive a written explanation of the reason for denial. You have the right to have the plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce the
above rights. For instance, if you request materials from the plan and do not receive them within 30 days, you may file suit in a federal court. In
such a case, the court may require the plan administrator to provide the materials and pay you up to $100 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control
of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. If it
should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance
from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are
successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim frivolous. If you have any
questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest Area Office of the U.S.
LaborManagement Services Administration, Department of Labor.
CLAIM REVIEW PROCEDURES If a claim is denied or partly denied, you will be notified in writing and given
an opportunity for a review. The written denial will give: Specific reason(s) for denial;
If your claim is not paid correctly according to the insurance policy
provisions or if your claim is not acted on within a reasonable time, you may proceed to the review procedure stage, described below, as if the claim had been denied. Review Procedure:
Where a claim has been denied or partly denied, you may appeal the denial and have a review.
Within 90 days after you receive written notice that your claim has been denied, you or your representative may make a written
request for review to the Fund Administrator, Administration Company, 5500 Market Street, San Francisco, CA 94000.
Decision on review:
A decision will be made promptly and not later than 60 days after receipt of your request for review unless you are notified in writing that special circumstances require additional time. A final decision
will be made no later than 120 days after receipt of your request. The decision on review will be in writing and will include specific reasons for the decision.
The preceding information, as it pertains to the administration of the Trust, is not a part of your group insurance program as
underwritten by The Insurance Company but is provided for your information and assistance. The Administrator or Consultant can give you help that will be satisfactory in almost every case.
FILING YOUR CLAIM It is important that the Administrative Office have a completed enrollment form for you in the files. This form must be completed before claims can
be processed. If you have not completed an enrollment form, obtain one from your local union office or from the Administrative Office, complete the form and return it to the Administrative Office immediately. Obtain a claim form from the Administrative Office. Complete your portion
of the claim form in full and sign it in the space provided. If you wish payment to be made directly to the provider instead of to you, the form should also be signed in the space provided for assigning benefits. Attach
your itemized bill from your physician, surgeon or other provider; be sure that the bill for a prescription includes the nature and date of purchase, prescription number and the name of the physician who issued the
prescription. Submit the completed claim form with your itemized bills to the Claims Office:
Construction Workers Local No.1 Health & Welfare Trust Fund - Claims Office 1234 Market Street San Francisco, CA 94000
Your claim should be filed as soon as possible after the expense has been incurred.
GROUP INSURANCE PLANUnderwritten By THE INSURANCE COMPANY
(called the Company in this booklet) We have prepared this certificate booklet to describe your Group
Insurance Plan in nontechnical language. The following pages constitute your Certificate of Insurance, not the policy under which you are insured. The master policies numbers 00000 and 111111 have been issued to the Construction Workers Local No.1 Health & Welfare Trust Fund. Each eligible person and his eligible dependents are insured for the
benefits described in this booklet, subject to all the exceptions, limitations, and provisions of the Group Policies, providing the required premium has been paid. Premium is paid to insure each eligible person and his eligible dependents according to the rules of Eligibility shown in this booklet. In the event you
want to verify your eligibility, you may contact the Administrator. ELIGIBILITY
Initial Eligibility
The hours required for eligibility are subject to change at the discretion of the Trustees.
All members of Construction Workers Local No.1 who have been employed by members of the Construction Employers Association and by any individual employer with whom said Union has Collective Bargaining
Agreement, and who were eligible for coverage as of June 1, 1991, shall continue to be eligible for coverage for themselves and their dependents through August 31, 1991. Hours worked by said members between
January 1, 1991 and August 31, 1991, up to a maximum of 300 hours, shall be credited to their reserve accounts as of September 1, 1991, and said members shall be eligible for coverage as of that date if they meet the
continuing eligibility requirements as provided below.
All members of Local No.1 who are not eligible for coverage as of June 1, 1991 shall become eligible for coverage on the first day of the second month following the month in which said member has completed 500 hours
of work for one or more contributing employers within the previous 6-month period, provided, however, said 6-month period shall not extend back prior
to January 1, 1991. Upon initially qualifying for eligibility, each member shall have 300 hours credited to his or her reserve account. In order for a member to continue his coverage once said member becomes eligible, the member must work a minimum of one hundred (100)
hours per month. Any hours in excess of 100 hours worked by the member in any month may be accumulated by the member in a reserve. The reserve of hours may not exceed 300 hours. In the event a member
does not work 100 hours in any month, such member may withdraw enough hours from his reserve to qualify him for coverage. RetireesThose members of Local No.1 who have retired and are drawing pensions
through the Local No.1 Pension Fund and the employees of Local No.1 may be covered by contributing on their own behalf the premium for the coverage described in this booklet. The right of retirees to coverage must be elected at the time of retirement and if the retiring member desires to include a spouse or other dependent
that election must also be made at the time of retirement. If a retiree acquires a spouse after retirement, the spouse may be covered so long as
notice is given within 30 days of marriage. Surviving spouses of retirees who had been covered by the insurance described in this booklet by reason of premium payment by the retiree may retain coverage by
continuing to make such contributions.
Contributions under the above paragraphs shall be made payable to the Administrator by those seeking coverage and shall be made at least 15
days in advance of the period for which coverage is desired. No retroactive premiums shall be accepted. If any such person shall fail to make
premium payments when required hereunder, coverage shall lapse when the period for which premiums are paid expires. Benefits paid to a retiree and his spouse is reduced by all benefits which the patient is entitled to receive from Medicare Part A and Part B, even if
he has not enrolled in Medicare. To avoid loss of benefits, be sure to enroll in both Part A and Part B of Medicare. Limitation on Eligibility
In the event any member covered hereunder accepts employment in any capacity and of any duration from any contractor performing work covered by the Collective Bargaining Agreement within the jurisdiction covered by
said agreement, which contractor is not signatory to the Collective Bargaining Agreement, and any member covered hereunder who engages in work covered by said Collective Bargaining Agreement as a sole
proprietor who is not a signatory of the Collective Bargaining Agreement, and any member covered hereunder who becomes a partner or corporate officer of any employer engaged in work covered by said Collective
Bargaining Agreement when the employer is not a signatory of the Collective Bargaining Agreement shall lose coverage or benefits offered by the Health and Welfare Trust Fund as follows: (1) said member shall lose
all hours held in the said member's reserve; (2) said member and dependents shall immediately cease to be covered by the insurance or benefits offered by the Health and Welfare Trust Fund; (3) said member
and dependents shall not again become covered by any of the insurance or benefits offered by the Health and Welfare Trust Fund until the member has met the Fund requirements for initial eligibility as set forth in this
booklet following termination of the work which was not under the Collective Bargaining Agreement as previously described in this paragraph. Failure to Maintain Eligibility
A member's insurance under this plan will terminate at the end of that month in which his reserve of hours worked falls below the minimum of eligibility for benefit as explained above, or upon entry into the military
service (other than a temporary tour of duty not exceeding 30 days). If a member's insurance would otherwise terminate because of working less than 100 hours per month, and the member wishes to maintain coverage
thereafter, the member must apply to the Trust Fund office to continue the insurance at the member's own expense as provided below in the section entitled, "Group Continuation Plan."
Reinstatement
An insured member who ceases to meet the eligibility requirements shall again become insured if he works and/or has credited to him from his reserve account at least 100 hours within the six-calendar month period
subsequent to the cessation of his insurance. Such reinstatement shall be effective on the first day of the second calendar month following
compliance with this work requirement. If the member does not become reinstated within a six-month calendar month period, any reserve of hours
which he has shall cease to exist and he shall again become eligible for insurance only upon completion of the initial eligibility requirement as set forth above. Disability Provisions
A special provision has been made to allow credits during periods of disability. In order to be eligible to receive disability credits, a member
must have been covered as a result of working hours and not as a result of his or her own contributions, and the member must further apply for continuation coverage pursuant to the section in this document entitled
"Group Continuation Plan." Upon application for disability credits to the Plan Administrator, a member shall be eligible to receive disability credits
for a period equal to the period, not to exceed 12 months, in which the member was continuously covered, as a result of hours worked by the member, prior to the member's disability. The period for which the
disabled member is entitled to receive continuation coverage due to the member's disability shall be reduced by an equal period of time. Members who are disabled shall be credited with five hours per day, up to a
maximum of 100 hours per month, for each working day they were disabled; provided, that if a member is disabled on each working day of a calendar month and there were fewer than 20 working days in said month,
the member shall be credited with 100 hours for that month. Once disability credit hours have been used to satisfy the eligibility requirements
of a member as provided in this section, the member is not again eligible to receive disability credit hours until such time as the member has again
been eligible for coverage as a result of working hours. Disability credit hours are not available to retirees. A member shall be deemed to be disabled within the meaning of this section if the Board of Trustees determines, upon the basis of medical
evidence, that the member is unable to work with the tools of the trade by reason of any medically determinable physical or mental impairment. Effective DateEach person shall become insured on the date said person becomes
eligible. However, if the person is hospital confined on his or her eligibility date, said person will not become insured until he has been finally discharged from the hospital. DEPENDENTS TO BE INSURED "Eligible Dependent" shall mean (a) your lawful spouse and (b) each unmarried child who has not attained his 19th birthday. If your unmarried
child is dependent on you for support and maintenance and is attending school or college as a fulltime student taking twelve (12) or more hours per
semester, or the equivalent thereof on a quarterly basis, he shall continue to be considered an eligible dependent to (i) the date he ceases to be a
fulltime student or (ii) the date he attains his 24th birthday, whichever is earlier.
In addition, if your unmarried child's insurance would otherwise terminate solely due to attainment of age nineteen, he shall continue to be considered an eligible dependent if he is incapable of selfsustaining
employment by reason of mental retardation or physical handicap, if he became so incapable prior to attainment of age nineteen. Written evidence of such incapacity must be furnished to the Administrator with respect to
any such child within thirtyone days after attainment of such limiting age. Proof of the continued existence of such incapability shall be furnished to the Administrator from time to time at its request. Those dependent children who are eligible for benefits as eligible Persons
under the Policy shall not be considered eligible dependents hereunder. "Child" includes a stepchild, adopted child and foster child provided such
child is chiefly dependent upon the insured person for support and maintenance. Foster children are not covered if you choose the Kaiser option. Where an insured Person is also eligible as a dependent spouse under the Policy, benefits hereunder will be payable to an individual as an insured
Person and as insured Dependent consecutively, and each Person may claim such benefits on behalf of his or her dependent children up to the maximum amounts provided under the Policy, but in no event will the
aggregate of benefits payable exceed 100% of the actual eligible charges incurred during a period of disability.
Dependents in military service are not eligible for coverage under this policy.
When Dependent Coverage BeginsYour dependents' coverage becomes effective on the same date as your
coverage. If you acquire a dependent after your insurance is in effect, the insurance on that dependent begins on the date the dependent acquires
the status of an "eligible dependent." A minor child who is placed with you for adoption will be covered from the time the child is placed in your custody. However, a dependent who is confined to a hospital on the date that insurance would otherwise become effective will become insured upon their
release from the hospital. However, if a newborn dependent child incurs charges for services over and above the usual cost of necessary charges for routine wellbaby care because of injury, illness, congenital defects or
premature birth, insurance begins from birth. TERMINATION OF INSURANCE Member
Your insurance will terminate at the earliest of: 1. the termination of this Policy; 2. the termination of your membership in the classes eligible for insurance;
3. the modification of the Policy to terminate insurance on the class of Persons to which you belong; 4. your failure to make any contribution, if requested, toward the
insurance hereunder. The Fund provides for voluntary contributions as described under "Eligibility"; 5. the cessation of payments on your behalf;
6. the modification of the Policy to terminate one or more forms of insurance shown in the "Schedule of Insurance";
7. if you stop work because of a labor dispute, you shall continue to be insured, up to a maximum of six months after the date of cessation of work or until you secure fulltime employment with another employer,
whichever first occurs, provided: a) you make timely payment of the then current monthly contribution or monthly premium as the case may be, plus 20% of such amount to the
Policyholder hereunder (or to your Union as the case may be); and b) at least 75% of the Persons insured as of the date of cessation of work
continue coverage as provided by timely premium payments; and c) any premium for this Policy which is due and unpaid as of the date of
cessation of work shall first be paid within the Policy's Grace Period; 8. when you no longer meet the qualifications as described under "Eligibility".
Dependent
The insurance of a Dependent to terminate at the earliest of: 1. the termination of your insurance; 2. the modification of the Policy to terminate Dependents' insurance;
3. the termination of your status as an eligible Dependent; 4. the modification of the Policy to terminate one or more forms of Dependents' insurance in the "Schedule of Insurance"; 5. when the employee is no longer covered, except that upon the death of a covered employee, that employee's dependents shall remain covered until the end of the current coverage period. EMPLOYER SUPPLEMENTARY FUND Voluntary Contributions by Employers
The Trustees have established a separate "Employers' Trust Fund" for the purpose of providing Employers the same benefits that eligible employees
are entitled to receive under the Plans established by the Trustees for covered employees. All funds received by the Trustees from "Employers"
are to be accounted for separately. The benefits provided employers are obtained by way of a supplementary policy or contract and, to the extent
possible and lawful, shall provide the same benefits for contributing Employers and their dependents as are furnished covered employees and at the same cost per individual per month, plus an administrative fee to be
determined by the Trustees, as is charged by the insurance companies for participating contributing Employees and their dependents. Eligibility as an Employer
An Employer is defined as an individual proprietor, partnership or corporation which employs employees represented by Local 1 of the Construction Employers Association under the terms of a collective
bargaining agreement between said employer and Local 1. In order to be eligible to participate in the Plan provided through the "Employers Trust Fund" an Employer, must meet the following conditions:
1. If the Employer is an individual proprietor or partnership, persons who are individual proprietors or partners will be eligible to participate in this Plan if: (a) the Employer has made at least 1,000
hours of contributions in the preceding twelve (12)-month period to the Construction Workers Local 1 Health and Welfare Trust on behalf of all its employees represented by Local 1 and performing
work covered by a collective bargaining agreement with Local 1; (b) the individual proprietor or partner is actively working on a full-time basis in the construction industry within the geographical
jurisdiction of Local 1; and (c) the individual proprietor's or partnership's principal office is located within the geographical jurisdiction of Local 1; or
2. If the Employer is a corporation, persons who are officers of, or who own more than 5% of, the Employer corporation will be eligible
to participate in this Plan if: (a) the Employer corporation has made at least 1,000 hours of contributions in the preceding twelve (12)-month period to the Construction Workers Local 1 Health and
Welfare Trust on behalf of all its employees represented by Local 1 and performing work covered by a collective bargaining agreement with Local 1; (b) the officer or owner is actively working on a
full-time basis in the construction industry within the geographical jurisdiction of Local 1; and (c) the Employer Corporation's principal office is located within the geographical jurisdiction of Local 1.
In the event a person meets the above conditions for participation, he shall
be eligible to participate as an "employer" for the ensuing twelve (12)-month period and may also cover all (but not less than all) employees
of such Employer who are not represented by Local 1 of the Construction Employers Association or any other Union or are not covered by another
bona fide Group Health & Welfare Plan but who are actively engaged in the affairs of the business of the Employer. The term 'Employer' shall also
include officers and office employees of any Association party to the contract.
When Employer Coverage CommencesIn order to make voluntary contributions to the Employer Trust Fund, the
applicant must complete an application form provided by the Trustees.
No individual may make voluntary contributions for retroactive coverage. Coverage will commence on the first day of the month following the period
in which four consecutive monthly premium payments have been paid to the Trust Administrator on or before the fifteenth day of each said month. A threemonth premium amount shall be held as a reserve and monthly
premiums, the amount of which are to be determined by the Trust Administrator pursuant to the provisions in this booklet, shall thereafter be paid in advance on or before the fifteenth day of the month, commencing
with the month in which coverage begins. (For example, if an applicant completes an application form on or before February 15 and makes monthly premium payments, as determined by the Trust Administrator, on
February 15, March 15, April 15, and May 15, the applicant will be covered commencing June 1. The premium payment for July will be due on June
15 and the premium payment for each month thereafter will be due on the 15th day of the previous month.)In the event a monthly payment is not made timely and termination of
coverage occurs as provided below, reinstatement will be permitted upon the satisfaction of the original eligibility requirements as stated in the two preceding paragraphs.
When Employer Coverage Terminates
1. Any Employer participation on behalf of the Employer or on behalf of any employee covered under the Employer Supplementary Fund shall terminate when the Employer fails to make timely
contribution of the monthly payment established by the Trustees and the reserve account for said Employer or Employee is insufficient to make the monthly premium payment.
2. An Employer will no longer be eligible to make contributions to the Employer separate Fund if he is delinquent in effecting his
contributions on behalf of employees covered by a collective bargaining agreement between the Local 1 of the Construction Employers Association and such Employer to any fund, trust or
account to which contributions are required by such an agreement
3. An Employer will no longer be eligible to make contributions, in the event the Trustees, in their sole opinion and discretion,
determine that the employer has abused the privilege of making contributions to the Employer Fund by listing individuals who are not, in fact, full-time employees of such employer or who were
placed on the Employer's payroll primarily for the purpose of obtaining coverage for such individual and/or his dependents.
4. When an individual proprietor, or a partner in a partnership, or an officer of owner of a corporation, or any other person eligible for participation as an 'Employer' voluntarily ceases to be actively
working on a full-time basis in the bricklaying and masonry industry within the geographical jurisdiction of Local 1 of the Construction Employers Association, or voluntarily ceases to be actively
engaged on a full-time basis in the activity which qualified such person to come within the definition of 'Employer,' the coverage of such person under this Plan shall terminate.
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