Common use of Request to Arbitrate Clause in Contracts

Request to Arbitrate. Grievance # In regard to GRIEVANCE REPORT FORMS I, II AND III (attached): request is hereby made for a hearing before an arbitrator as provided in Level Five of the grievance procedure. (Signature of Association President/Designee) (Date) Received by Superintendent or his/her Designated Representative: (Signature) (Date) APPENDIX B SCHEDULE OF MEDICAL BENEFITS Benefit Plan - PPO All health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays, Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expenses and Maximums section of this SPD for more details. Benefits are subject to all provisions of this Plan including any benefit determination based on an evaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and General Exclusions sections of this SPD for more details. Important: Prior authorization may be required before benefits will be considered for payment. Failure to obtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the Care Management section of this SPD for a description of these services and prior authorization procedures.