Forms and Notices
Documents Related to Health & Welfare Fund Forms
Our documents are in PDF. You may need to download the latest version of Adobe Reader.
Coordination of Benefits (COB)
Member's Application for Benefits-Short Term Disability
Accident Details Form
Short Term Disability Continuation Form
Transition of Care Form
Health Reimbursement Form
Plan 13 Waiver Form
Plan 14 Waiver Form
Plan 16 Waiver Form
Dependent Child Certification
DavisVision Direct Reimbursement Claim Form
Application/Beneficiary Form
Application/Beneficiary Form-Spanish
Coverage Medical Retiree for Debit Direct
Authorization Form
Documents Related to Health & Welfare Fund Notices
New Health Insurance Marketplace Coverage Options and Your Health Coverage:
Highmark Blue Shield Transition Letter to Participants
CHIP Notice 2024
2021 No Surprises Act/Balance Billing Plan Disclosures Notice to Participants
2013 Marketplace Notice to Participants
Important Information About Your Appeal Rights
Protected Health Information to Parents Notice - October 2018
Questions? Contact Us!
Please note, If you are looking to apply for benefits please contact the Fund office by telephone.
In order to avoid a delay in responding to your question(s), please do not leave duplicate messages (e.g., via emails, website submissions or voicemails). We will do our best to respond to your message within 24 business hours. Thank you.
