form

Information Request - OPEB

Please provide a summary of your provisions and Other Post-Employment Benefit (OPEB) valuation needs as indicated below. Note that some entries include a drop-down menu.

The answers will be used to provide a competitive fee quote corresponding to the anticipated work effort. Averages and approximations may be used where appropriate.

Supporting documents (plan document, summary plan description, or other written documentation of your administration policies) are also helpful if you have them readily available.

Other-Post Employment Benefit (OPEB) Plan Overview

Entity Name:

Contact Name:

Address:

Phone:

area code 1 -

Fax:

area code 1 -

E-mail:

Eligibility and Coverage:

Service Requirement:

Age Requirement:

Other:

Please note if different groups have different eligibilities or if anyone should be excluded from the valuation.

Benefit/Type of Insurance:

Included even if provided through pension plan
			Pre-65 Medical
			Post-65 Medical
			Dental
			Vision
			Prescription Drug
Other Benefits Not Listed, or special grandfathering
Describe the nature of any "defined contribution-like" benefits provided:
Included if not provided by pension plan
Life Insurance
Long-term disability (retiree only, retiree plus spouse, none)
Accumulated sick leave (converted to offset OPEB)
Special termination benefit enhancements
Group legal benefits

Other-Post Employment Benefit (OPEB) Plan Overview
Number of Participants: (approximate)	Actives
	Retirees and dependents
If count varies by benefit, explain here:
Breakdown of liabilities:	Describe any breakdown you require by subgroups Will you want results presented using different alternative assumption sets (e.g. various discount rates, health care trend rates)?
Presentation of results:	Do you prefer a conference call or meeting? Will you want results presented using different alternative assumption sets (e.g. various discount rates, health care trend rates)?
Link to Other Programs:	Are you paying into a State/Federal program while individuals are active where the benefits will later be used to offset the cost of the retirees' OPEB?
Funding:	Included, even if provided through pension plan: Currently Funding through trust. Anticipate exploring trust options.
Fiscal year: