Back references from Display under index in Download for Download index: Heath and Welfare Forms
| Title | Type | Description |
|---|---|---|
| DISABILITY FORM |
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 |
SUBROGATION FORM/INJURY INQUIRY |
|
| MEDCO DIRECT_COB FORM.pdf | ||
| FT MEDICARE RX CREDITABLE COVERAGE NOTICE.doc | ||
| PT MEDICARE RX NON CREDITABLE COVERAGE NOTICE.doc | ||
| DURABLE MEDICAL EQUIPMENT AND SUPPLIES CLAIM FORM.pdf | ||
| OPTICAL CLAIM FORM | ||
| PART TIME BENEFIT OPT OUT AND PLAN SECONDARY NOTICE | ||
| FULL TIME BENEFIT SUMMARY INSERT INCLUDING DENTAL SCHEDULE | ||
| 2011 PART TIME PLAN AFFORDABLE CARE ACT WAIVER NOTIFICATION | ||
| PART TIME BENEFIT SUMMARY INCLUDING DENTAL SCHEDULE | ||
| DEPENDANT CERTIFICATION |
CERTIFICATION OF ELIGIBILITY FOR DEPENDENT COVERAGE FOR CHILDREN AGE 19 - 26 |
BRIAN A. PETRONELLA
PRESIDENT, LOCAL 371 UFCW
MARCH 1956 - AUGUST 2010
