Refund Request – Important Plan Notice

Please Read Carefully Before Submitting

Refunds are governed strictly by the Plan’s Terms and Conditions and applicable insurance laws and regulatory guidelines. Submission of this request does not create a right to a refund and does not guarantee approval. Premiums paid based on member provided information that was incomplete, inaccurate, misleading, or not timely updated may be considered properly due and non refundable. All requests are subject to review and determination in accordance with Plan provisions and governing rules.

Purpose of This Form

This refund request form is intended for limited, specific circumstances only.

Refund requests should only be submitted if you are requesting a refund outside of the standard 90 day refund policy.

If your situation already qualifies under the Plan’s Terms and Conditions, any applicable refund would have been processed automatically. In those cases, submission of this form is not required.

Member Responsibility and Timely Notice

As a Member, you are responsible for notifying the Plan Administrator within 90 days of any change that may affect your eligibility, including but not limited to:

• Retirement
• Separation from the union
• Cessation of full dues payments
• Change in employer, job classification, or work status
• Leave of absence, paid or unpaid
• Actively working status changes
• Any other change that impacts eligibility under the Plan

If notice is not provided within the required 90 day period, the Plan will rely on the information on file. In such cases, premiums are deemed properly drafted and are not refundable, even if eligibility is later determined to have changed.

Accuracy of Enrollment Information

Coverage eligibility and premium billing are based entirely on the information provided by the Member at the time of enrollment and as subsequently updated by the Member.

If enrollment information was incomplete, inaccurate, misleading, or materially misrepresented, or if enrollment questions were answered inaccurately, refunds will not be issued beyond what is expressly permitted under the Plan’s Terms and Conditions and applicable law.

If enrollment information changes prior to your coverage effective date and you do not notify the Plan Administrator, your enrollment is considered incomplete, inaccurate, and misrepresented.

Material misrepresentation or omission may result in denial of refund requests and may also impact coverage determinations.

Circumstances for Review

The Plan recognizes that certain situations may occur that could prevent timely notice.

If circumstances beyond your control prevented you from providing notice within the required timeframe, you may submit this request for review. In such cases:

• A clear and detailed explanation is required
• Supporting documentation must be provided from your union, employer, or another relevant third party source
• Documentation must substantiate both the eligibility change and the reason timely notice was not possible

Each Member is responsible for their own notifications regarding eligibility changes. It is not the responsibility of the union or employer to notify the Plan Administrator on your behalf. Statements indicating that you believed someone else was notifying the Plan Administrator are not grounds for a refund.

Please do not upload documents issued by Union One, as those records are already maintained internally.

Documentation and Review Standards

• Refund requests submitted without required documentation will be denied
• Requests that fall outside Plan provisions or regulatory guidelines will be denied
• Requests submitted for the purpose of circumventing Plan eligibility rules or refund limitations will be denied
• Submission of this form does not guarantee approval
• All determinations are made in accordance with the Plan’s Terms and Conditions, carrier requirements, and applicable law

The Plan Administrator’s determination is final, subject to applicable rights under governing regulations. If a request is denied, you will be provided with the reason for denial and information regarding any available appeal rights.