1. EVERETT SCHOOL EMPLOYEE BENEFIT TRUST
    2. NOTICE OF APPEAL DENIAL
    3. [insert quote from relevant provision(s)]


    [Enrollment/Eligibility]


     





    EVERETT SCHOOL EMPLOYEE BENEFIT TRUST





    NOTICE OF APPEAL DENIAL


     

    TO:                  Date:      

             

             

     [name and address of claimant or authorized representative]

     
    RE: Everett School Employee Benefit Trust (“Trust”): [insert employee’s name] –Claim to be enrolled in or eligible for a plan offered under the Trust


     

    Dear [claimant or authorized representative name]:

     

    This letter responds to your request for review of the enrollment/eligibility denial that was made on [insert date] by the District. The Trust received your request for review on [insert date]. You requested enrollment in or eligibility for a plan offered through the Trust. We have carefully considered the information provided and applied the terms of the plan that apply to your request for review. For the reason(s) set out below, we have determined that you are not eligible for enrollment in a plan offered through the Trust, and accordingly, the decision following review is that your request for enrollment/eligibility must be denied.

     
    1. Specific Reason for Denial
     


    The specific reason(s) for denial of benefits and the Trust’s agreement with that denial is [insert description or reason].
     
    2. Applicable Plan Provisions
     


    The provisions(s) in the plan document on which the denial is based is [insert citation to section] found on page(s) [insert page number]. The cited provision(s) states:
     





    [insert quote from relevant provision(s)]
     
    This decision on review is the Trust’s final decision.
     
    Sincerely,
     
     
          
    Trustee(s)
    Everett School Employee Benefit Trust

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    Seattle-3203541.1 0053709-00001