Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| PART I, LINE 1 AND PART III, LINES 1 AND 4A - ORGANIZATION'S MISSION: | TO PROVIDE HEALTH BENEFITS TO ELIGIBLE ACTIVE PARTICIPANTS AND | THEIR COVERED DEPENDENTS. THE PLAN ALSO PROVIDES HEALTH BENEFITS TO SELF-PAY PARTICIPANTS AND RETIREES FOR WHICH A CONTRIBUTION IS RECEIVED. PART VI, LINE 11B: FORM 990 WAS REVIEWED BY THE ADMINISTRATIVE OFFICE PRIOR TO BEING FILED. THE ADMINISTRATIVE OFFICE WILL NOTIFY THE BOARD OF TRUSTEES OF UNUSUAL OR SIGNIFICANT ITEMS, IF NOTED. PART VI, LINE 12C: TRUSTEES ARE REQUIRED TO NOTIFY THE TRUST OF ANY CHANGES IN THEIR INTEREST THAT COULD GIVE RISE TO CONFLICTS. PART VI, LINE 19: THE PLAN'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE MAINTAINED AT THE ADMINISTRATIVE OFFICE AND ARE AVAILABLE UPON REQUEST. |
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