Forms To Download

 Attention: If you would like to submit a form electronically, please send a request for the appropriate form to fund@ufcw1776benefitfunds.org. We will then send you a form via a secure website to complete and return to us  electronically. If you have any questions, please contact us at: 1-800-458-8618

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Click on form  and print from next screen.                            
Physical Well-Being Benefit Direct Reimbursement Form Request for Change of Address
Acme-Super Fresh-Pathmark-HSI-Citterio-UFCW Local 1776 (New Hires)-Dreshertown Shop N Bag- FT Student Verification Form
Weekly Group Accident & Sickness

Accident & Sickness Disability Claim Form

Health and Accident Report
Salary Deferral Agreement/Change Form
Prescription Incentive Program Claim Form Declaration of Spouse Health Coverage
Dental Change Request form Preventive and Wellness Reimbursement Form
Dental Benefits Program Education Benefit Reimbursement Request
Dental Care Provider Nomination Request Flexible Benefits Plan Claim Form
2004 Other Prescription Drug Benefit information Vision Provider Nomination Request
Legal Service Provider  Selection Form Dental Referral Form
Website Claim Form Download Disclaimer

  The ability to download these forms does not guarantee your entitlement to benefits or benefit payment.
The benefits that each participant is entitled to receive are determined by the collective bargaining agreement between the Union and your contributing employer.
  If you submit a form for a benefit for which you are not entitled, you will be notified that your form could not be processed and it will state the reason. Questions concerning your eligibility for benefits should be directed to the Fund office or refer to your Summary Plan Description booklet.