|Forms To Download|
Attention: If you would like to submit a form electronically, please send a request for the appropriate form to firstname.lastname@example.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
Note: Print document in portable text format - PDF Format. If you want to print the text format , you need to have Acrobat Reader installed on your computer. If do no have Acrobat Reader installed on your computer, just click on the Acrobat Reader Icon and download this free software.
|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
Accident & Sickness Disability Claim Form
Health and Accident Report
|Salary Deferral Agreement/Change Form|
|Prescription Incentive Program Claim Form||
Declaration of Spouse
Change Request form
Preventive and Wellness Reimbursement Form||
Benefit Reimbursement Request||
Provider Nomination Request||
Benefits Plan Claim Form
2004 Other Prescription Drug Benefit
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.