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

                                                                             2020 FULL TIME ENROLLMENT FORM   
 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