Documents Available

Summary Plan Description - (2006 Edition)

Summary Plan Description is a booklet that describes all benefits provided by the Fund.

SPD-2006 Edition Form

Schedule of Benefits - Plans A, B, C, D - Effective January 1, 2017

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
Schedule of Benefits - Plan C Pamphlet
Schedule of Benefits - Plan D Pamphlet

Email Communication Authorization

Form to authorize email communication

Authorization for Email Communication Form

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 Workerís 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

Smoker NonSmoker Change Form

If your smoking status has changed since your annual open enrollment, complete this form and submit it to the Fund Office.

Smoker NonSmoker Change Form

Spousal Coverage Verification Form

A Spousal Coverage Verification Form must be completed if you are adding a spouse to your policy. If your spouse is unemployed or self employed, this form must be notarized and submitted yearly.

Spousal Coverage Verification Form

Enrollment-Beneficiary Form

Enrollment-Beneficiary Form will allow you to change your election, add/drop spouse and/or dependent child(ren), change beneficiary or address.

Enrollment-Beneficiary Form

HIPAA Privacy Information

HIPAA Privacy Information is a leaflet to review that explains the Fundís Privacy Practices.

HIPAA Privacy Information

HIPAA Privacy Form for Plan Participant, Dependent Children, and 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

2018 Summary of Benefits and Coverage

Summary of Benefits and Coverage - Plan A
Summary of Benefits and Coverage - Plan B
Summary of Benefits and Coverage - Plan C
Summary of Benefits and Coverage - Plan D