ERISA Administrative Record Request

ERISA ADMINISTRATIVE RECORD AND PLAN DOCUMENT REQUEST

SEND VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED

Date: [__/__/____]

FROM:

Name: [________________________________]

Address: [________________________________]

City, State, ZIP: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

Social Security Number (last 4 digits): XXX-XX-[____]

Employee ID (if applicable): [________________________________]

TO:

[Plan Administrator Name]
[Company/Organization Name]
[Address]
[City, State, ZIP]

AND/OR:

[Claims Administrator/Insurance Company Name]
[Address]
[City, State, ZIP]

RE: REQUEST FOR ADMINISTRATIVE RECORD AND PLAN DOCUMENTS

Plan Name: [________________________________]

Claim Number: [________________________________]

Policy/Group Number: [________________________________]

Claimant Name: [________________________________]

Date of Claim: [__/__/____]

Dear Plan Administrator:

I am a participant [and/or beneficiary] in the above-referenced employee benefit plan. Pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), I hereby request copies of the documents specified below.

This request is made pursuant to:

• ERISA § 104(b)(4), 29 U.S.C. § 1024(b)(4)
• ERISA § 503, 29 U.S.C. § 1133
• 29 C.F.R. § 2560.503-1(h)(2)(iii)
• 29 C.F.R. § 2560.503-1(m)(8)

PART I: PLAN DOCUMENTS REQUESTED UNDER 29 U.S.C. § 1024(b)(4)

Under ERISA § 104(b)(4), I request copies of the following documents:

Plan Governing Documents

☐ The complete Plan Document (not just the Summary Plan Description)
☐ Summary Plan Description (SPD), including all amendments
☐ Summary of Material Modifications (SMM)
☐ The insurance contract, policy, or certificate of coverage
☐ All amendments to the Plan Document
☐ Trust agreement (if applicable)
☐ Adoption agreement (if applicable)
☐ Administrative services agreement
☐ Any side letters or amendments to the insurance contract

Financial and Annual Reports

☐ Most recent Form 5500 Annual Report and all schedules
☐ Summary Annual Report (SAR)
☐ Audited financial statements (if applicable)

Other Required Documents

☐ Collective bargaining agreement (if applicable)
☐ Any instruments under which the Plan is established or operated

PART II: CLAIM FILE AND RELEVANT DOCUMENTS UNDER 29 C.F.R. § 2560.503-1

Pursuant to 29 C.F.R. § 2560.503-1(h)(2)(iii) and (m)(8), I request copies of all documents, records, and other information "relevant" to my claim, including but not limited to:

Documents Relied Upon in Benefit Determination

☐ All documents relied upon in making any adverse benefit determination
☐ All medical records reviewed
☐ All reports from consulting physicians, nurses, or medical reviewers
☐ All vocational assessments or reports
☐ Functional capacity evaluations
☐ Independent medical examination reports
☐ Surveillance materials (including videos, photographs, and investigator reports)

Documents Submitted, Considered, or Generated

☐ All documents submitted by me or on my behalf
☐ All documents considered in making the benefit determination
☐ All documents generated in the course of making the determination
☐ All internal notes, memos, and correspondence regarding my claim
☐ All telephone notes and call logs
☐ All emails relating to my claim

Policy and Guidance Documents

☐ Any statements of policy or guidance concerning the denied treatment, benefit, or my diagnosis
☐ Clinical guidelines or criteria used to evaluate my claim
☐ Medical necessity criteria
☐ Disability evaluation guidelines
☐ Any internal protocols or procedures for claims handling

Expert and Consultant Information

☐ All reports, opinions, or communications from any medical or vocational expert consulted
☐ The names, credentials, and qualifications of all medical reviewers
☐ The names, credentials, and qualifications of all vocational experts
☐ Contracts or agreements with peer review organizations
☐ Compensation arrangements with reviewing physicians

Administrative Process Documents

☐ Documents demonstrating compliance with administrative processes and safeguards required by 29 C.F.R. § 2560.503-1(b)(5)
☐ Conflict of interest policies
☐ Claims handling procedures

PART III: ADDITIONAL SPECIFIC REQUESTS

Denial-Related Documents

☐ All denial letters issued in connection with my claim
☐ All appeal decision letters
☐ Template denial letters used for similar claims

Communications

☐ All correspondence between the Plan and my employer regarding my claim
☐ All correspondence between the Claims Administrator and any third parties regarding my claim
☐ All correspondence with my treating physicians

Definition and Interpretation Documents

☐ Documents defining "disability" under the Plan
☐ Documents defining "own occupation" and "any occupation"
☐ Documents explaining how "material duties" are determined
☐ Interpretive guidelines for Plan terms

FORMAT AND DELIVERY

Please provide the requested documents in the following format:

☐ Paper copies mailed to the address above
☐ Electronic copies (PDF format) via email to: [________________________________]
☐ Electronic copies on CD/USB drive mailed to the address above

DEADLINE FOR RESPONSE

Under ERISA § 104(b)(4), 29 U.S.C. § 1024(b)(4), you are required to furnish the requested documents within 30 days of receipt of this request.

Failure to comply with this request may result in:

1. Statutory penalties of up to $110 per day under ERISA § 502(c)(1), 29 U.S.C. § 1132(c)(1)
2. Court-ordered production of documents
3. Attorneys' fees and costs

FEE NOTIFICATION

I understand that you may charge a reasonable fee for copying costs. If the total copying cost will exceed $[50], please contact me in advance for authorization. Please note that under 29 C.F.R. § 2560.503-1(h)(2)(iii), documents relevant to my claim must be provided free of charge.

DOCUMENT PRESERVATION NOTICE

Please be advised that you are hereby notified to preserve all documents, records, electronically stored information, and tangible items that may be relevant to my claim, including but not limited to:

• All documents identified in this request
• All electronic communications (emails, text messages, instant messages)
• All electronic files and databases
• All backup tapes and archives
• All audio recordings of telephone calls

Destruction, alteration, or deletion of any such materials may constitute spoliation of evidence.

CERTIFICATION

I certify that I am a participant [or beneficiary] of the above-referenced Plan and am entitled to receive the requested documents under ERISA.

Signature: ___________________________________

Printed Name: [________________________________]

Date: [__/__/____]

TRACKING INFORMATION

Date Request Sent: [__/__/____]

Method of Delivery:
☐ Certified Mail, Return Receipt Requested
☐ FedEx/UPS with tracking
☐ Hand Delivery

Tracking Number: [________________________________]

Date Receipt Confirmed: [__/__/____]

30-Day Deadline for Response: [__/__/____]

FOLLOW-UP LOG

IF DOCUMENTS ARE NOT PROVIDED

If the Plan Administrator fails to provide the requested documents within 30 days:

1. Send a follow-up letter referencing this request and the missed deadline
2. Document all communications with dates and content
3. Consider filing a complaint with the Department of Labor, Employee Benefits Security Administration (EBSA)
4. Consult an ERISA attorney about filing a civil action under 29 U.S.C. § 1132(c)(1) for statutory penalties

DEPARTMENT OF LABOR CONTACT INFORMATION

Employee Benefits Security Administration (EBSA)
U.S. Department of Labor
200 Constitution Avenue, NW
Washington, DC 20210
Phone: 1-866-444-EBSA (3272)
Website: www.dol.gov/agencies/ebsa

SOURCES AND REFERENCES

• 29 U.S.C. § 1024(b)(4) - Disclosure Requirements
• 29 U.S.C. § 1132(c)(1) - Penalties for Non-Disclosure
• 29 C.F.R. § 2560.503-1 - Claims Procedure
• 29 C.F.R. § 2575.502c-1 - Civil Penalties
• Cigna Corp. v. Amara, 563 U.S. 421 (2011)

This template is provided for educational and informational purposes. Seek qualified legal counsel for specific advice regarding ERISA document requests.