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Site Index
Trust Information
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Active Health Plan Forms
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| General |
- Interplan Claims & Appeals Procedure - This gives general information on Interplan and the claims procedure.
- Walgreens Health Initiatives (Mail Order Form) - The Plan encourages you to obtain all maintenance medications via mail order using this form. Both you and the Plan save considerably by purchasing prescriptions this way.
- Kaiser Account Change Form - You must notify Kaiser immediately of any change in your family such as the birth of a child or marriage. Failure to submit this form to Kaiser within 30 days of a family change may result in no coverage for the person to be added until the next open enrollment period.
- Designation of Beneficiary Form - This Form is designed for Participants, not receiving a pension, who want to designate their beneficiary. Please complete this Form and return it to the Administrative Office if the Participant wants to update or designate his/her beneficiary.
- Enrollment Form - Part I - This form is needed at the time of initiating your coverage with the Fund. The form provider dependent information, as well as coordination of benefits information. This form only needs to be submitted if you are newly enrolled in the Fund.
- Enrollment Form - Part II - This form is for participants who have selected Union Labor Life coverage to select primary physicians for each covered family member.
- Notice of Open Enrollment - Active - There is an open enrollment that annually takes place in December for change of coverage effective January 1.
- Step Child Insurance Enrollment - Form confirming support of your children or step-children.
| Claim Forms |
- Medical Eye Services - Claim Form (Policy 95-003) - Medical eye services claim form.
- Active Claim Form -
| Brochures & Communications |
- Prescription Drug Benefit Summary - Summary of Plan changes related to the prescription drug benefit effective 3-1-2004.
- Summary of Material Modifications (2003) - Summary of Material Modifications to the Plan.
- Summary of Material Modifications (2002) - The Summary of Material Modifications explains significant changes to the Plan since the publication of the last Summary Plan Description.
| Disability |
- ULL - Total & Permanent Disability Statement of Claimant - !!!This form is used if you become permanently disabled. Your life insurance under the Union Labor Life group policy will remain in force and will not require any premium payment on your part as long as you continue to be permanently disabled and comply periodically with the insurance company's requests for verification of your disability status.
| Provisional Plan |
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These printable forms are in PDF (Portable Document) format.
To read and print them, you need the free Adobe Acrobat Reader (which is probably already installed in your system). If you do need to install it, click the "Get Acrobat Reader" logo. |
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