40 BENEFIT PLAN PROVISIONS All documents relating to th e Snellings Walters Insurance Agency Welfare Benefit Plan , including the Evidence/Certificate of Coverage for each plan, Listing of Network Providers, Contribution Rates, General COBRA Notice , General HIPAA , Medicare Creditable Coverage Notice and any other relevant Plan Documents or Notices, are available to employees and their dependents . Plan participants may receive a paper copy of any of the above documents free of charge by contacting the Plan Administrator . In addition to this Wrap Document p lease refer to the applicable Subsidiary Contract and any other applicable plan document for each Welfare Program’s specific details. These documents will include the description of benefits, cost - sharing provisions, requirements for use of network providers and circumstances by which benefits may be excluded or denied . STATUTORY PROVISIONS Family and Medical Leave Act (FMLA) To be eligible for FMLA leave, employees must have worked for covered employers for a total of 12 months (which do not need to be consecutive) and for at least 1,250 hours in the previous 12 months , immediately preceding the leave . The 1,250 - hour threshold can be met whether employees work full - time or part - time. Employers with multiple worksites are covered by FMLA if the worksites are within a 75 - mile radius of each other and the number of employees equals 50 or more by counting employees at all worksites. The 75 - mile radius is measured in surface miles, rather than linear miles. If you go on a qualified unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), the following rules will apply. Only to the extent required by FMLA (among other things, this means only for the duration of a qualifying leave), the employer will continue to maintain your health plan benefits on the same terms and conditions as though you were still an active employee. Except as otherwise provided by FMLA, your Plan participation will cease when the Plan Administrator learns that you do not intend to return to work after your leave. Y our Plan participation will immediately cease upon expiration of your FMLA leave, if you fail to return to work at such time , unless otherwise required by federal, state , or local law . Except as otherwise provided in the FMLA, if you fail to return to work after the FMLA leave, you will be required to reimburse the Employer for the cost of the coverage provided to you while you were on FMLA leave (the cost equals the COBRA premium, without a 2% add - on, and minus any employee contribution you already made). For more information on FMLA, please contact the Employer, where you may obtain a summary of your rights under FMLA without charge. The Employer has the responsibility to provide you with prior written notice of the terms and conditions under which payment must be made. Failure to make payment within 30 days of the due date established by your Employer will result in the termination of coverage. If coverage is terminated for failure to make payments while you are on an approved F amily or Medical L eave of A bsence, coverage for you and your eligible dependents will be automatically reinstated on the date you return to employment if you and your dependents are otherwise eligible