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IMPORTANT NOTICES

YOU ARE INVITED TO ATTEND THE CT AFL-CIO YOUNG WORKERS FORUM UNIONS & OCCUPY:  WHERE DO WE GO FROM HERE? DATE: THURSDAY, FEBRUARY 2 TIME: 5:30 - 7:00 P.M.  LOCATION: HARTFORD PUBLIC LIBRARY DOWNTOWN, SEMINAR ROOM 2ND FLR ​500 MAIN STREET, HARTFORD, CT 06103     UNIONS AND OCCUPY FLYER CLICK HERE      

Heath and Welfare Forms

Click the health and welfare forms below to download and print them from your computer. You will need Adobe Acrobat Reader, a free download.

Title Type Description
Dental form
application/pdf icondental_form.pdf
2011 PART TIME ENROLLMENT CARD
application/pdf icon2011_part_time_enrollment_card.pdf
Statement of Disability
application/pdf iconLOCAL 371 DISABILITY FORM.pdf

A two-page form. First page is for member's completion and the second page is for doctor's to complete.

SUBROGATION FORM/INJURY INQUIRY
application/pdf iconHWW_STATEMENT_SUBROGATION_FORM_0.pdf

SUBROGATION FORM/INJURY INQUIRY

MEDCO DIRECT_COB FORM.pdf
application/pdf iconMEDCO DIRECT_COB FORM_0.pdf
FT BENEFIT ENROLLMENT FORM 2011
application/pdf iconft_enrollment_form.pdf
FT MEDICARE RX CREDITABLE COVERAGE NOTICE.doc
application/msword iconFT MEDICARE RX CREDITABLE COVERAGE NOTICE.doc
PT MEDICARE RX NON CREDITABLE COVERAGE NOTICE.doc
application/msword iconPT MEDICARE RX NON CREDITABLE COVERAGE NOTICE.doc
DURABLE MEDICAL EQUIPMENT AND SUPPLIES CLAIM FORM.pdf
application/pdf iconDURABLE MEDICAL EQUIPMENT AND SUPPLIES CLAIM FORM.pdf
OPTICAL CLAIM FORM
application/pdf iconOPTICAL CLAIM FORM
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IB Image

BRIAN A. PETRONELLA

PRESIDENT, LOCAL 371 UFCW

MARCH 1956 - AUGUST 2010

United Food & Commercial Workers Union, Local 371

290 Post Road West
P.O. Box 470
Westport, CT 06881-0470
Tel (203) 226-4751
Call Toll Free 1-800-882-5571

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