Summary Plan Description for Plan (A)

(Click on any of the links underlined and in blue colored text below to download that file to your computer.)

PLAN A SUMMARY PLAN DESCRIPTION EFFECTIVE 06/01/09.pdf (544 Kb) Last Modified: 08/07/2009

SUMMARY MATERIAL MODIFICATION JUNE 2013 VACCINATIONS .PDF (21 Kb) Last Modified: 06/19/2013

SUMMARY MATERIAL MODIFICATION 2012.PDF (40 Kb) Last Modified: 05/09/2012

SUMMARY MATERICAL MODIFICATION MARCH 2012 HEARING CARE BENEFIT.pdf (34 Kb) Last Modified: 03/20/2012

SUMMARY MATERIAL MODICATION MARCH 2012 GRANDFATHERING STATUS.pdf (26 Kb) Last Modified: 03/20/2012

SUMMARY MATERIAL MODIFICATION MARCH 2011-PDF (94 Kb) Last Modified: 03/28/2011

SUMMARY MATERIAL MODIFICATION JANUARY 2011.pdf (425 Kb) Last Modified: 01/06/2012

SUMMARY MATERIAL MODIFICATION DECEMBER 2009.pdf (664 Kb) Last Modified: 12/10/2009

GLOSSARY OF HEALTH COVERAGE AND MEDICAL TERMS.pdf (92 Kb) Last Modified: 11/29/2012

STATEMENT OF PRIVACY PRACTICES.PDF (81 Kb) Last Modified: 09/18/2012

PATIENT PROTECTION AND AFFORDABLE CARE ACT MAILING NOV 2010.pdf (561 Kb) Last Modified: 11/17/2010

AFFADAVIT OF AVAILABLE HEALTH COVERAGE FOR CHILDREN AGED 19-26.pdf (25 Kb) Last Modified: 11/21/2012

TRUSTEE CHANGES KEVIN HARVEY REPLACES DONALD FIORE, PAT SANTORO REPLACES DONALD LESLIE.PDF (65 Kb) Last Modified: 08/29/2011

Claim Forms for Plan (A)

 You may download and open any of the claim forms we provide for your convenience.

MEDICAL CLAIM FORM.PDF (262 Kb) Last Modified: 04/16/2012

DENTAL CLAIM FORM.pdf (486 Kb) Last Modified: 03/12/2009

MEMBER AUTHORIZATION TO RELEASE HEALTH INFORMATION.pdf (17 Kb) Last Modified: 07/31/2003

DEPENDENT OVER 18 YEARS OLD AUTHORIZATION TO RELEASE HEALTH INFORMATION.pdf (17 Kb) Last Modified: 07/21/2003

AUTHORIZATION TO RELEASE HEALTH INFORMATION TO THIRD PARTY.pdf (19 Kb) Last Modified: 09/03/2003

 SUB FORM.pdf (13 Kb) Last Modified: 03/15/2007

MEDCO HEALTH MAIL-ORDER FORM.PDF (148 Kb) Last Modified: 04/16/2012

MEDCO HEALTH DRUG REIMBURSEMENT FORM.PDF (86 Kb) Last Modified: 04/16/2012

Please note: The material contained in this website is subject to the actual hard copy material furnished by the Fund Office. If there is any inconsistency between the material contained in this website and the actual hard copy material furnished by the Fund Office, the hard copy written material shall be determinative.