REQUEST FOR SUMMARY PLAN DESCRIPTION AND PLAN DOCUMENTS

PURSUANT TO 29 U.S.C. § 1024(b)(4)

SEND VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED

Date: [__/__/____]

FROM (Plan Participant or Beneficiary):

Name: [________________________________]

Address: [________________________________]

City, State, ZIP: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

Participant Status:

☐ Current Employee/Plan Participant
☐ Former Employee/Plan Participant
☐ Beneficiary of Participant [Name: ________________________________]
☐ COBRA Participant
☐ Alternate Payee under QDRO

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

Employee ID Number: [________________________________]

TO (Plan Administrator):

[Plan Administrator Name/Employer Name]
[ERISA Plan Document Request]
[Address]
[City, State, ZIP]

RE: WRITTEN REQUEST FOR PLAN DOCUMENTS PURSUANT TO ERISA § 104(b)(4)

Dear Plan Administrator:

Pursuant to Section 104(b)(4) of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1024(b)(4), I hereby request copies of the documents identified below relating to the employee benefit plan(s) in which I am a participant or beneficiary.

Under ERISA, you are required to furnish the requested documents within 30 days of receipt of this written request. Failure to comply may subject the Plan Administrator to penalties of up to $110 per day from the date of such failure or refusal, as provided by 29 U.S.C. § 1132(c)(1) and 29 C.F.R. § 2575.502c-1.

SECTION 1: PLAN IDENTIFICATION

This request pertains to the following plan(s):

Plan 1:

Plan Name: [________________________________]

Plan Type:

☐ Health/Medical Insurance Plan
☐ Dental Insurance Plan
☐ Vision Insurance Plan
☐ 401(k) Retirement Plan
☐ Defined Benefit Pension Plan
☐ Life Insurance Plan
☐ Short-Term Disability Plan
☐ Long-Term Disability Plan
☐ Flexible Spending Account (FSA)
☐ Health Savings Account (HSA)
☐ Other: [________________________________]

Plan Number (if known): [________________________________]

Plan 2 (if applicable):

Plan Name: [________________________________]

Plan Type: [________________________________]

Plan Number (if known): [________________________________]

Plan 3 (if applicable):

Plan Name: [________________________________]

Plan Type: [________________________________]

Plan Number (if known): [________________________________]

SECTION 2: DOCUMENTS REQUESTED

I request copies of the following documents for each plan identified above:

Core Plan Documents

☐ Summary Plan Description (SPD) - The current SPD and all Summaries of Material Modifications (SMMs) issued since the last complete SPD

☐ Plan Document - The complete, formal plan document as adopted by the plan sponsor

☐ Trust Agreement - Any trust agreement or custodial agreement under which plan assets are held

☐ Insurance Contracts/Policies - All insurance contracts, certificates, or policies providing benefits under the plan

☐ Collective Bargaining Agreement - Any collective bargaining agreement applicable to the plan (if applicable)

Financial and Reporting Documents

☐ Annual Report (Form 5500) - The most recent annual report filed with the Department of Labor

☐ Summary Annual Report (SAR) - The most recent summary annual report

☐ Audited Financial Statements - Audited financial statements for the plan (if applicable)

☐ Actuarial Reports - Actuarial valuation reports (for defined benefit plans)

Administrative Documents

☐ Plan Amendments - All amendments to the plan document not yet incorporated into the SPD

☐ Administrative Services Agreement - Any agreement with a third-party administrator

☐ Claims Procedures - Detailed claims and appeals procedures

☐ Internal Rules and Guidelines - Any internal rules, guidelines, protocols, or policies used in administering claims

☐ Fee Disclosure Documents - Documents disclosing plan fees and expenses (for retirement plans)

Claims-Related Documents (If Applicable)

☐ Claim File Documents - All documents, records, and information relevant to my claim for benefits (per 29 C.F.R. § 2560.503-1(h)(2)(iii))

☐ Documents Relied Upon - All documents relied upon in making any adverse benefit determination

☐ Medical Policies - Any medical policies, clinical guidelines, or coverage criteria applicable to my claim

☐ Vendor Communications - Correspondence between the plan and any insurance company, TPA, or claims administrator regarding my benefits

SECTION 3: SPECIFIC DOCUMENT REQUESTS

In addition to the general categories above, I specifically request:

1. [________________________________]

2. [________________________________]

3. [________________________________]

4. [________________________________]

5. [________________________________]

SECTION 4: REASON FOR REQUEST (Optional)

☐ To understand my benefits and coverage
☐ To prepare an appeal of an adverse benefit determination
☐ To verify calculation of my benefits
☐ To prepare for a claim submission
☐ To evaluate potential legal claims
☐ To assist with retirement planning
☐ To comply with divorce proceedings/QDRO
☐ Other: [________________________________]

SECTION 5: DELIVERY INSTRUCTIONS

Please send the requested documents to the following address:

Name: [________________________________]

Address: [________________________________]

City, State, ZIP: [________________________________]

☐ I also request electronic copies be sent to: [Email Address]

☐ I am willing to pay reasonable copying costs for documents (please advise of costs before copying)

☐ I request an index of all documents maintained by the Plan Administrator relating to the plan(s)

SECTION 6: LEGAL BASIS FOR THIS REQUEST

Statutory Authority

Under 29 U.S.C. § 1024(b)(4):

"The administrator shall, upon written request of any participant or beneficiary, furnish a copy of the latest updated summary plan description, and the latest annual report, any terminal report, the bargaining agreement, trust agreement, contract, or other instruments under which the plan is established or operated."

Regulations

The Department of Labor regulations at 29 C.F.R. § 2520.104b-1 provide that documents must be furnished "not later than 30 days after such request."

Penalties for Non-Compliance

Under 29 U.S.C. § 1132(c)(1):

"Any administrator... who fails or refuses to comply with a request for any information which such administrator is required by this subchapter to furnish to a participant or beneficiary... may in the court's discretion be personally liable to such participant or beneficiary in the amount of up to $100 [now $110] a day from the date of such failure or refusal, and the court may in its discretion order such other relief as it deems proper."

Who May Request Documents

ERISA defines eligible requestors as:
- Participants (29 U.S.C. § 1002(7)): Current or former employees eligible for benefits
- Beneficiaries (29 U.S.C. § 1002(8)): Persons designated to receive benefits, including dependents

SECTION 7: VERIFICATION OF STATUS

To verify my status as a participant or beneficiary entitled to receive these documents:

☐ I am a current employee enrolled in the plan(s)
☐ I am a former employee who was enrolled in the plan(s) from [__/__/____] to [__/__/____]
☐ I am a beneficiary/dependent of the participant named [________________________________]
☐ I am receiving COBRA continuation coverage
☐ I am an alternate payee under a QDRO dated [__/__/____]
☐ I may become eligible for benefits under the plan(s)

Employer: [________________________________]

Dates of Employment: [__/__/____] to [__/__/____] or ☐ Current

Last Four Digits of SSN: [____]

SECTION 8: ACKNOWLEDGMENT OF RIGHTS

I understand that:

1. The Plan Administrator must provide the requested documents within 30 days of receiving this written request.

2. The Plan Administrator may charge a reasonable fee for copying (not to exceed 25 cents per page under DOL guidance).

3. If the Plan Administrator fails to provide the documents within 30 days, I may be entitled to seek statutory penalties of up to $110 per day.

4. I have the right to examine plan documents at the principal office of the Plan Administrator during normal business hours.

5. This request does not waive any of my rights under ERISA.

SECTION 9: DEADLINE FOR RESPONSE

This request is dated [__/__/____].

Documents must be provided on or before [30 days from request date: __/__/____].

If you are unable to comply with this request for any reason, please notify me in writing immediately, specifying:
- The reason for non-compliance
- When the documents will be available
- Any additional information needed to process this request

SECTION 10: CONTACT INFORMATION FOR QUESTIONS

If you have any questions regarding this request, please contact:

Name: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

Preferred method of contact: ☐ Phone ☐ Email ☐ Mail

CERTIFICATION

I certify that I am a participant or beneficiary entitled to receive the documents requested above, and that the information provided in this request is true and accurate to the best of my knowledge.

Signature: ___________________________________

Printed Name: [________________________________]

Date: [__/__/____]

ENCLOSURES (if any)

☐ Proof of participant/beneficiary status
☐ Copy of employee ID card
☐ Copy of benefits enrollment confirmation
☐ COBRA election notice
☐ QDRO (if alternate payee)
☐ Other: [________________________________]

IMPORTANT REMINDERS

Before Sending This Request:

☐ Verify the correct Plan Administrator (often the employer, not the insurance company)
☐ Use the correct address for the Plan Administrator
☐ Make a copy of this request for your records
☐ Send via certified mail, return receipt requested
☐ Note the date sent and calculate the 30-day deadline

After Sending This Request:

☐ Track the certified mail delivery
☐ Calendar the 30-day deadline
☐ If documents are not received within 30 days, send a follow-up letter
☐ Consider consulting an ERISA attorney if the Plan Administrator fails to respond

Common Issues to Avoid:

• Wrong Recipient: The request must go to the Plan Administrator, not the insurance company
• Not in Writing: Oral requests do not trigger the 30-day deadline or penalties
• Unclear Request: Be specific about which documents you need
• Not a Participant/Beneficiary: Only participants and beneficiaries have this right

FOLLOW-UP LETTER (If Documents Not Received Within 30 Days)

Date: [__/__/____]

SECOND REQUEST - URGENT

Dear Plan Administrator:

On [date of original request], I submitted a written request pursuant to 29 U.S.C. § 1024(b)(4) for plan documents. More than 30 days have passed, and I have not received the requested documents.

Under ERISA, your failure to provide these documents may result in personal liability of up to $110 per day. As of today, [____] days have elapsed since my original request.

Please provide the requested documents immediately. If I do not receive the documents within 14 days, I will consider all legal options, including seeking statutory penalties in federal court.

Sincerely,

[________________________________]

SOURCES AND REFERENCES

• 29 U.S.C. § 1024(b)(4) - Furnishing of Plan Documents
• 29 U.S.C. § 1132(c)(1) - Penalties for Failure to Provide Documents
• 29 C.F.R. § 2520.104b-1 - Disclosure Requirements
• 29 C.F.R. § 2520.102-3 - Contents of Summary Plan Description
• Department of Labor ERISA Advisory Opinions
• DOL Field Assistance Bulletin 2012-02R

This template is provided for educational and informational purposes. Seek qualified legal counsel for specific advice regarding your ERISA document request or for assistance in enforcing your rights.