Descriptions and links for Downloadable Forms

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Summary Plan Description - (SPD- 2006 Edition)

Summary Plan Description is a booklet that describes all benefits provided by the Fund.
SPD-2006 Edition Form

Schedule of Benefits- Plan A
Schedule of Benefits- Plan B

The Schedule of Benefits Grid is part of your Summary Plan Description. This pamphlet is a quick reference of benefits that are provided to you through the plan.
Schedule of Benefits-Plan A Pamphlet
Schedule of Benefits-Plan B Pamphlet

Short-Term Disability Form

If you miss work due to an illness or injury, a Short-Term Disability Form must be completed. In order to claim short term disability benefits, you must be eligible for Health & Welfare Benefits at the time of disability. Any injuries or accidents related to work are not covered under Short-Term disability and must be filed under your employers Worker’s Compensation.
Short-Term Disability Form

Accident Questionnaire

An Accident Questionnaire must be completed if the Fund Office receives a claim and the diagnosis could be related to an injury or accident. If you have recently received a denied claim pending for accident information, please complete this questionnaire and submit to the Fund Office for review.
Accident Questionnaire

Dental Claim Form

Dental Claim Form must be completed for all dental services. Your dentist may provide this form for you
Dental Claim Form

Out-Of-Network Vision Claim Form

An Out-Of-Network Vision Claim Form must be completed for all routine eye exams, contacts and/or glasses from an out-of-network provider. All receipts must be obtained and submitted with Vision Claim Form for reimbursement.
Vision Claim Form

Open Enrollment Information

Open Enrollment Information is a print out, listing some of the rules for premium share with frequently asked questions.
Open Enrollment Information

Annual Open Enrollment Form

Annual Open Enrollment Form must be completed yearly to elect or decline your Health & Welfare Benefits. Please refer to FAQ’s for other documentation that is needed to cover dependents
Annual Open Enrollment Form

Enrollment Change Form (Mid-Year Enrollment)

Enrollment Change Form must be completed if a life-changing event occurs and the plan participant wants to modify their previous enrollment election.
Enrollment Change Form (Mid-Year Enrollment)

Spousal Coverage Verification Form

Spousal Coverage Verification Form must be completed annually and anytime there is a change regarding your spouse’s employment status.
Spousal Coverage Verification Form

Enrollment-Beneficiary Form

Enrollment-Beneficiary Form must be completed to add or remove a dependent. This form is also used to change your life insurance beneficiary. Please refer to FAQ’s for other documentation that is needed to cover dependents.
Enrollment-Beneficiary Form

HIPAA Privacy Information

HIPAA Privacy Information is a leaflet to review that explains the Fund’s Privacy Practices.
HIPAA Privacy Information

HIPAA Privacy Form for Plan Participant
HIPAA Privacy Form for Dependent Children
HIPAA Privacy Form for Spouse

HIPAA Privacy Form must be completed for anyone over the age of 18 to authorize a representative to speak on their behalf.
HIPAA Privacy Form for Plan Participant
HIPAA Privacy Form for Dependent Children
HIPAA Privacy Form for Spouse