Click the health and welfare forms below to download and print them from your computer. You will need Adobe Acrobat Reader, a free download.
You may download a copy of the 2020 Full Time Enrollment form by clicking the above link. Form must be completed and returned to the Fund office no later than December 15, 2019
Title Type Description VISION BENEFIT IMPROVEMENTS EFFECTIVE JULY 1, 2013 DISABILITY FORM DISABILITY FORM A two-page form. First page is for member’s completion and the second page is for doctor’s to complete. HWW INQUIRY/SUBROGATION SUBROGATION FORM/INJURY INQUIRY OPTUMRX REIMBURSEMENT FORM FT MEDICARE RX CREDITABLE COVERAGE NOTICE.doc HIPAA PRIVACY AUTHORIZATION FORM AUTHORIZATION TO DISCLOSE INFORMATION TO A THIRD PARTY EYEMED VISION CLAIM FORM FOR OUT OF NETWORK CLAIMS COB QUESTIONAIRE 2018 COB QUESTIONAIRE 2018 FORM MAY BE FILLED AND PRINTED FOR SIGNATURE AND MAILED TO LOCAL 371 FOR PROCESSING PT & ACA DENTAL SCHEDULE OF BENEFITS This schedule only applies to PART TIME & ACA QUALIFIED EMPLOYEES AS OF JANUARY 1, 2014
THERE IS NO DEPENDENT COVERAGE INCLUDED FOR THESE BENEFITS
FT & FT CLERK DENTAL SCHEDULE OF This schedule only applies to FULL TIME EMPLOYEES AND FULL TIME CLERKS AS OF JANUARY 1, 2014