General Forms
These forms can be completed for any applicable fund or plan.
Health & Welfare Plan
Health & Welfare Summary Plan Description (H&W-SPD)
Children’s Health Insurance Program (CHIP)
Summary of Material Modifications (SMMs)
Dec-2023: Changes to Retiree Health & Welfare Program, Hearing Aids, Disability Benefit, Board Members
May-2023: End of COVD-19 Emergency Pan Changes
Dec-2022: Change in Dialysis Benefits/Current Board of Trustees
Dec-2022: Mastectomy Benefits
Dec-2022: Children’s Health Insurance Program (CHIP)
Jan-2022: The No Surprises Act
Jan-2022: Amended Active Eligible and Covered Medical Expenses (pages 17, 42-43, & 53)
Dec-2021: Mastectomy Benefits
Dec-2021: Children’s Health Insurance Program (CHIP)
Dec-2020: Mastectomy Benefits
Dec-2020: Children’s Health Insurance Program (CHIP)
April-2020: COVID-19 and TelaDoc
Dec-2019: Mastectomy Benefits
Dec-2019: Children’s Health Insurance Program (CHIP)
Nov-2018: Mastectomy Benefits
Nov-2018: Children’s Health Insurance Program (CHIP)
Nov-2018: Telemedicine Benefit and Expert Second Option Services
May-2018: Medical Revisions to your Health Plan Benefits (Active)
Dec-2017: Mastectomy Benefits
Dec-2017: Children’s Health Insurance Program (CHIP)
Dec-2016: Mastectomy Benefits
Dec-2016: Children’s Health Insurance Program (CHIP)
April-2016: Medical Revision to Your Medical Plan
Medical Schedule of Benefits
Schedule of Medical Plan 500
Schedule of Medical Plan 551
Schedule of Medical Plan 552
Schedule of Medical Plan 553
Schedule of Medical Plan 554
Medical Summary of Benefits
2024 Summary of Benefits and Coverage Plan 500
2024 Summary of Benefits and Coverage Plan 551
2024 Summary of Benefits and Coverage Plan 552
2024 Summary of Benefits and Coverage Plan 553
2024 Summary of Benefits and Coverage Plan 554
Dental
Schedule of Dental Plan 601
Schedule of Dental Plan 602
Schedule of Dental Plan 603
Schedule of Dental Plan 604
Schedule of Dental Plan 605
Schedule of Dental Plan 606
Vision
Schedule of Vision Plan 701
Schedule of Vision Plan 702
Schedule of Vision Plan 703
Schedule of Vision Plan 704
Weekly Income (Disability) Benefits
Schedule of Weekly Income (Disability) Plan 500
Schedule of Weekly Income (Disability) Plan 801
Schedule of Weekly Income (Disability) Plan 802
Schedule of Weekly Income (Disability) Plan 803
Schedule of Weekly Income (Disability) Plan 804
Life and Accidental Death & Dismemberment Benefits
Schedule of Life and AD&D Plan 901
Schedule of Life and AD&D Plan 902
Schedule of Life and AD&D Plan 903
Planned Surgery Benefit
Health & Welfare Forms
Adult Dependent Opt-Out Application (online form)
Annual Medical/Dental Update Form (online form)
Application to Continue Coverage for Handicapped Child (PDF form)
Authorization Agreement for Preauthorized Payments Form (online form)
Authorization for Release of Information (online form)
Disability: Application for Weekly Income Disability Benefits (PDF form)
Disability: Supplementary Disability Claim Form (PDF form)
Enrollment/Change Form (online form)
Medical-Dental Reimbursement Form (PDF form)
Prescription Caremark Claim Form (PDF form)
Prescription Caremark Foreign Claim Form (PDF form)
Prescription Caremark Mail Order Claim Form (PDF form)
Request for Confidential Communication (online form)
Step/Foster Child Questionnaire (online form)
Retiree HRA Plan
Pension Plan
Pension Plan Summary Plan Description (Pension-SPD)
Annual Funding Notice
Pension IRS Form 5500
Summary of Material Modifications (SMMs)
Notice of Benefit Changes (mailed Jan-2024)
Notice of Benefit Changes (mailed Apr-2022)
Notice of Benefit Changes (mailed Dec-2021)
Notice of Benefit Changes (mailed Sept-2020)
Notice of Benefit Changes (mailed Mar-2020)
Notice of Benefit Changes (mailed Jan-2020)
Notice of Benefit Changes (mailed Feb-2019)
Notice of Benefit Changes (mailed Jun-2017)
Pension Plan Forms
Annual Certification of Retiree Signature (online form)
Direct Deposit Authorization (online form)
Pension Plan Enrollment and Beneficiary Designation Form (online form)
IRS W-4P (2024) Withholding Certificate for Periodic Pension or Annuity Payments (online form)
Post-Retirement Service Determination Request Form (online form)
Revocation of Voluntary Suspension of Retirement Benefit Form (online form)
Voluntary Suspension of Retirement Benefit Form (online form)
Retirement Savings Plan
Retirement Savings Plan Summary Plan Description (RSP-SPD)
Retirement Savings Account IRS Form 5500 (external link)
Summary of Material Modifications (SMMs)
None at this time.
Retirement Savings Plan Forms
RSP Enrollment and Beneficiary Designation Form (online form)
RSP Employee Voluntary Contribution Form (PDF form)
Legal Plan
Legal Plan Summary Plan Description (LP-SPD)
IdentityForce Identity Theft Protection Flyer
Summary of Material Modifications (SMMs)
None at this time.
Legal Plan Forms
Participant’s Statement Form (online form)
Attorney Intake Form (online form)
Legal ACH Form (online form)
Retiree Legal Enrollment Form (online form)
