This is one of two forms required to be completed to apply for the continuation of the participant’s Welfare Fund life insurance benefit when a participant has become totally and permanently disabled prior to reaching 60 years of age. The completed form is to be returned to the Fund Office.

This is one of two forms required to be completed to apply for the continuation of the participant’s Welfare Fund life insurance benefit when a participant has become totally and permanently disabled prior to reaching 60 years of age. The completed form is to be returned to the Fund Office.

To be completed by the participant, notarized and returned to the Fund Office to determine continuation of coverage for a 19-23 year old child.

To be completed to apply for the COBRA premium assistance subsidy.

To be completed to apply for dental benefits.

This is one of two forms required to be completed to apply for continuation of insurance for an overage child that is permanently physically or mentally disabled.

This is one of two forms required to be completed to apply for continuation of insurance for an overage child that is permanently physically or mentally disabled.

Describes the change in determining eligibility based on the four calendar quarter hour rule.

Completion of this form is mandatory for enrollment to the Plan and required in order to add or remove your eligible dependents. This form is also used to designate the beneficiary for the life insurance benefit if applicable.

To be completed by the participant and educational institution and returned to the Fund Office to determine continuation of coverage for a 19-23 year old child.

To be completed by the participant, notarized and returned to the Fund Office to apply for dependent coverage to a grandchild. 

Describes the benefits available under the Low Cost.

To be completed and notarized when a natural parent does not have insurance for their child.

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

To authorize the Plan to provide health information to a personal representative.

Brief explanation of the privacy notice with privacy request forms.

To be completed by the natural parent and notarized to determine whether a child born out of wedlock qualifies as a covered dependent under the Plan.

To be completed to determine whether a stepchild qualifies as a covered dependent under the Plan.

For Full-Time Students on a Medically Necessary Leave of Absence or Change of Enrollment (Age 19-22). This is incompliance to Michelle's Law.

To be completed when expenses for an illness or accident may be compensable by an action against a third party.

A breakdown of the Plan benefits.

To be completed by the participant and their physician to apply for the weekly sickness and accident benefit.

Physician certification of continuing disability.