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HRA Claim Form
Please note that HRA benefits are paid by the Fund on a monthly basis. To ensure timely payment of each claim submission completed claim forms must be submitted to the Fund Office no later than the second Tuesday of each calendar month.
Change of Address Form
Beneficiary Designation Form
Special Enrollment Form (Adult Child to Age 26)
Benefit Enrollment Form
Universal Enrollment Form
PHI Authorization Form
PHI Cancellation Form
Weekly Unemployment Benefit Form - NEW
Certification of Medical Necessity Form
Qualified Relative Certification Form
Dental Claim Form Out-of-Network
Vision Claim Form Out-of-Network
Hearing Aid Claim Form
Medicare Claim Form
Notarized Affidavit of Current Marriage
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