Claims Administrator Document for ERISA Plan

Via Certified Mail, Return Receipt Requested

Plan Administrator
Costco Wholesale Corporation
[Address]



RE: Claimant/Insured: John Doe
Social Security Number: XXXXXXXX
Plan Name: Costco Wholesale Corporation Employee [type of plan] Plan

Dear Plan Administrator:

Pursuant to 29 U.S.C.A. §1024(b)(4), please forward me a copy of the Trust Document (commonly known as the “Plan Document”), Summary Plan Description (SPD) (and any amendments thereto since the inception of the Plan), and Form 5500 for the above-referenced Plan. 

I have also requested your claims administrator (XYZ Insurance Company) send these documents to me, in a letter dated this day as well. However, please do not refer me back to [XYZ Insurance Company] for these documents. As the Plan Administrator of the subject [describe whether medical, disability, pension] plan, you also have a fiduciary duty to ensure that these documents are sent to me.

I await your prompt reply. Thank you for your assistance in this matter.



Very truly yours,


John Doe claimant/insured​