General Forms
These forms can be completed for any applicable fund or plan.
Dependent Alternate Address Form (online form)
Correspondence Address Change Form (online form)
Health & Welfare Plan
Health & Welfare Summary Plan Description (H&W-SPD)
Notice of Privacy Practices
Appeal Procedures
Summary Annual Report 2023
Children’s Health Insurance Program (CHIP)
Summary of Material Modifications (SMMs)
None at this time.
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)
Explanation of Accident and/or Injury (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)
Travel Cost Comparison (PDF form)
Travel Reimbursement Checklist (PDF form)
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)
Temporary Exception to the Return-to-Work Rules 2024
Retirement Savings Plan
Qualified Default Investment Alternative Report – 2024 Plan Year
Retirement Savings Plan Summary Plan Description (RSP-SPD)
Retirement Savings Account IRS Form 5500 (external link)
Summary Annual Report 2023
John Hancock Getting Started Guide
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
IdentiftyForce FAQs
First Choice Health EAP Flyer
Summary Annual Report 2023
Summary of Material Modifications (SMMs)
Notice of Benefit Changes – Self-Payment Waiver and New Eldercare Benefit – July 2024
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)
