| For Eligible Participants of the UFCW Local 1776 and Participating Employers Health and Welfare Fund |
| Plan administered by: UFCW Local 1776 and Participating Employers Health & Welfare Fund |
| Delaware |
| Florida |
| New Jersey |
| New York |
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Important Note! To use the Plan, you must contact the Fund office for a claim form and to determine your vision benefit eligibility. Claim form must be presented to a participating doctors on your first visit. |