General Forms

These forms can be completed for any applicable fund or plan.

Dependent Alternate Address Form (online form)

Correspondence Address Change Form (online form)

Health & Welfare Plan

Health & Welfare Summary Plan Description (H&W-SPD)
Notice of Privacy Practices
Appeal Procedures

Summary of Material Modifications (SMMs)

Dec-2023: Changes to Retiree Health & Welfare Program

May-2023: End of COVD-19 Emergency Pan Changes
Dec-2022: Change in Dialysis Benefits/Current Board of Trustees
Dec-2022: Mastectomy Benefits
Dec-2022: Children’s Health Insurance Program (CHIP)
Jan-2022: The No Surprises Act
Jan-2022: Amended Active Eligible and Covered Medical Expenses (pages 17, 42-43, & 53)
Dec-2021: Mastectomy Benefits
Dec-2021: Children’s Health Insurance Program (CHIP)
Dec-2020: Mastectomy Benefits
Dec-2020: Children’s Health Insurance Program (CHIP)
April-2020: COVID-19 and TelaDoc
Dec-2019: Mastectomy Benefits
Dec-2019: Children’s Health Insurance Program (CHIP)
Nov-2018: Mastectomy Benefits
Nov-2018: Children’s Health Insurance Program (CHIP)
Nov-2018: Telemedicine Benefit and Expert Second Option Services
May-2018: Medical Revisions to your Health Plan Benefits (Active)
Dec-2017: Mastectomy Benefits
Dec-2017: Children’s Health Insurance Program (CHIP)
Dec-2016: Mastectomy Benefits
Dec-2016: Children’s Health Insurance Program (CHIP)
April-2016: Medical Revision to Your Medical Plan

Medical Schedule of Benefits

Schedule of Medical Plan 500
Schedule of Medical Plan 551
Schedule of Medical Plan 552
Schedule of Medical Plan 553
Schedule of Medical Plan 554

Medical Summary of Benefits

2024 Summary of Benefits and Coverage Plan 500
2024 Summary of Benefits and Coverage Plan 551
2024 Summary of Benefits and Coverage Plan 552
2024 Summary of Benefits and Coverage Plan 553
2024 Summary of Benefits and Coverage Plan 554

Dental

Schedule of Dental Plan 601
Schedule of Dental Plan 602
Schedule of Dental Plan 603
Schedule of Dental Plan 604
Schedule of Dental Plan 605
Schedule of Dental Plan 606

Vision

Schedule of Vision Plan 701
Schedule of Vision Plan 702
Schedule of Vision Plan 703
Schedule of Vision Plan 704

Weekly Income (Disability) Benefits

Schedule of Weekly Income (Disability) Plan 500
Schedule of Weekly Income (Disability) Plan 801
Schedule of Weekly Income (Disability) Plan 802
Schedule of Weekly Income (Disability) Plan 803
Schedule of Weekly Income (Disability) Plan 804

Life and Accidental Death & Dismemberment Benefits

Schedule of Life and AD&D Plan 901
Schedule of Life and AD&D Plan 902
Schedule of Life and AD&D Plan 903

Planned Surgery Benefit

Planned Surgery Flyer

Health & Welfare Forms

Adult Dependent Opt-Out Application (online form)

Annual Medical/Dental Update Form (online form)

Application to Continue Coverage for Handicapped Child (PDF form)

Authorization Agreement for Preauthorized Payments Form (online form)

Authorization for Release of Information (online form)

Disability: Application for Weekly Income Disability Benefits (PDF form)

Disability: Supplementary Disability Claim Form (PDF form)

Enrollment/Change Form (online form)

Medical-Dental Reimbursement Form (PDF form)

Request for Confidential Communication (online form)

Step/Foster Child Questionnaire (online form)

Travel Cost Comparison (PDF form)

Travel Reimbursement Checklist (PDF form)