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.

OTC COVID-19 Tests Reimbursement Form
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

Please keep in mind that the HRA feature is a negotiated benefit and must be included as part of your Collective bargaining Agreement to participate in the benefit. 
Download PDF

Plan 13 Waiver Form
Plan 14 Waiver Form
Plan 16 Waiver Form
Dependent Child Certification
DavisVision Direct Reimbursement Claim Form
Application/Beneficiary Form
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:

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.

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. 

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