Beneficiary Form
Change of Address
General Authorization Cancellation Form
General Authorization Form
Annual Medicare Part D Notice
DeltaCare USA DHMO Benefits Summary
Glosario de terminos medicos y seguros de salud - 2021
Glossary of Health Coverage & Medical Terms - 2021
HRA Benefits Mobile App Guide
HRA Benefits Portal Guide
MetLife PPO Benefits Summary (Effective October 1, 2023)
Notice of Privacy Practices
Overview for New Participants
Summary Plan Description - Nov 2019
Summary of Benefits & Coverage 2025
Supplement #1 - Nov 2019 (Establishing, Re-establishing and Maintaining Eligibility)
Supplement #10 - Oct 2020 (Clarification of Benefit for Cosmetic Surgery)
Supplement #11 - Oct 2020 (Vacation & Holiday Benefit Plan Improvements)
Supplement #12 - Dec 2020 (Pain Management Benefits)
Supplement #13 - Feb 2021 (COVID-19 Vaccinations)
Supplement #14 - May 2021 (COBRA 100% Premium Assistance and the Subsidized Self-Pay Program)
Supplement #15 - May 2021 (Subsidized Self-pay Program Eligibility Rules)
Supplement #16 - May 2021 (Out-of-Pocket Maximum)
Supplement #17 - May 2021 (Clarification of Covered Providers for Mental Health Services)
Supplement #18 - May 2021 (Establishing, Re-establishing, and Maintaining Eligibility)
Supplement #19 - Aug 2021 (High Cost Medication)
Supplement #2 - Nov 2019 (Re-establishing Eligibility)
Supplement #20 - Dec 2021 (Protections Against Balance Billing Under the No Surprises Act)
Supplement #21 - Feb 2022 (COVID-19 Testing)
Supplement #22 - May 2022 (Establishing, Re-Establishing, And Maintaining Eligibility)
Supplement #23 - June 2022 (Dependent Child Special Disability Benefits)
Supplement #24 - May 2023 (COVID-19 Testing and Vaccinations)
Supplement #25 - September 2023 (Colorectal Cancer Screening)
Supplement #26 - September 2023 (MetLife Dental PPO Replacing Delta Dental PPO Option)
Supplement #27 - June 2024 (Occupational and Speech Therapy)
Supplement #28 - September 2024 (Nutritional Counseling)
Supplement #29 - September 2024 (Substance Use Disorder Treatment)
Supplement #3 - Nov 2019 (Transition Employee Program)
Supplement #30 - November 2024 (Off-Label Prescription Medication)
Supplement #31 - November 2024 (Eligible Dependent)
Supplement #4 - Mar 2020 (New Vision Benefit)
Supplement #5 - Mar 2020 (COVID-19 Testing)
Supplement #6 - Jun 2020 (Merger of the Vacation & Holiday Fund into the Health & Welfare Fund)
Supplement #7 - Jul 2020 (Changes in Contribution Rates)
Supplement #8 - Sept 2020
Supplement #9 - Sept 2020 (Hospital Services for Dental Procedures)
Telemedicine Programs
VSP Grievance Process and Timely Access to Care Notice
VSP Member Benefits Summary
Your Rights And Protections Against Surprise Medical Bills
Annual Coordination of Benefits Form
Dental Enrollment Form (During Open Enrollment only)
Dental Enrollment Form (For those who have not yet made an election)
Disenrollment Form
Enrollment Form
HRA Reimbursement Form
Injury and Third Party Liability Form
PHI Request Form
Prescription Drug Claim Form
Vision Enrollment Form (For those who have not yet made an election)
Weekly Disability Application
Weekly Disability Continuation Form
Weekly Disability Notice of End of Total Disability
DeltaCare USA High Benefit Summary
DeltaCare USA Medium Benefit Summary
MetLife PPO Benefit Summary
Supplement #1 - Nov 2019 (Recalculation Premium Score)
Supplement #10 - May 2021 (Out-of-Pocket Max)
Supplement #11 - May 2021 (Mental Health Provider Clarification)
Supplement #12 - Aug 2021 (High Cost Medication)
Supplement #13 - Nov 2021 (Change in 2022 Monthly Premiums)
Supplement #14 - Feb 2022 (COVID-19 Testing)
Supplement #15 - Dec 2022 (2023 Monthly Premiums)
Supplement #16 - May 2023 (COVID-19 Testing and Vaccinations)
Supplement #17 - September 2023 (Colorectal Cancer Screening)
Supplement #18 - September 2023 (New Dental PPO Option)
Supplement #19 - November 2023 (Change in 2024 Monthly Premiums)
Supplement #2 - Nov 2019 (Change in 2020 Monthly Premiums)
Supplement #20 - June 2024 (Occupational and Speech Therapy)
Supplement #21 - September 2024 (Nutritional Counseling)
Supplement #22 - September 2024 (Substance Use Disorder Treatment)
Supplement #23 - November 2024 (Off-Label Prescription Medication)
Supplement #24 - November 2024 (Change in 2025 Monthly Premiums)
Supplement #3 - Mar 2020 (VSP)
Supplement #4 - Mar 2020 (COVID19 Testing)
Supplement #5 - Sept 2020 (Carryover Deductible Elimination)
Supplement #6 - Nov 2020 (Monthly Premiums Revised 2021)
Supplement #7 - Dec 2020 (Benefit Changes)
Supplement #8 - Jan 2021 (COVID-19 Vaccinations)
Supplement #9 - June 2021 (Eligibility Rules)
VSP Grievance Process And Timely Access To Care Notice
Annual Statement of Employment by Pensioner (Over Age 70 ½)
Dental Enrollment Form (During Open Enrollment Only)
Surviving Spouse Medical Dental & Vision Enrollment Form
Vision Enrollment Form (During Open Enrollment Only)
Supplement #1 - Nov 2019 (Change in How Fees will be Charged)
Supplement #2 - Jun 2020 (Hardship Distribution for FEMA Declared Disasters and Suspension of Minimum Required Distributions for 2020)
Supplement #3 - Sept 2020 (Distribution for the Birth or Adoption of a Child)
Supplement #4 - Oct 2020 (Distributions Transfers Change in Status)
Supplement #5 - Feb 2022 (Claims Processing Timeline)
Supplement #6 - Jan 2023 (Reduction in Fees)
Supplement #7 - June 2024 (Required Beginning Distributions, Involuntary Cash-Out of Small Accounts, Distributions to Terminally Ill Participants, and Disclaimer of Benefits)
Supplement #8 - August 2024 (Increase in Fees Charged to Accounts to Cover Plan Expenses)
Supplement #9 - March 2025 (Qualified Disaster Recovery Distributions)
Certification of Termination of Employment
Certification of Termination of Non-Covered Employment
DC Fund Enrollment/Change/Opt Out Form
Death Benefit Application
Fund Rollover Notice
Hardship Withdrawal Application
Home Repair Option Supplemental Form
Loss of Income Verification
Payment Due to QDRO Application
Qualified Birth Adoption Withdrawal
Qualified Disaster Recovery Distribution Application
Retirement Declaration Form
Retirement/Disability Distribution Application
Special Employer Account 401(a) Withdrawal Application
Special Notes Regarding Hardship Withdrawals
Terminal Illness Withdrawal Application
Termination Distribution Application
Termination Distribution for Landscape DCPP Only PreMerger 401a Funds
Termination Distribution for Non-Covered Employment
Supplement #1 - Jun 2020 (Merger of the Vacation & Holiday into the Health & Welfare Fund)
Interim Withdrawal Form
V&H Monthly Benefit Election Direct Deposit Form
V&H Normal Benefit Election Direct Deposit Form
Annual Funding Notice 2020
Annual Funding Notice 2021
Annual Funding Notice 2022
Annual Funding Notice 2023
Annual Funding Notice 2024
Supplement #1 - Nov 2019 (Modification in Suspension of Benefits Age 65 or Older)
Supplement #2 - Jul 2020 (Changes in Contribution Rates)
Supplement #3 - May 2021 (Pension Benefit Accrual Rate Increase)
Supplement #4 - Sept 2022 (Pension Benefit Increase)
Supplement #5 - Dec 2022 (Proof of Total Disability)
Supplement #6 - Dec 2024 (Modification of the Post-Retirement Civil Service Employment Rule for Pensioners under Age 70½)
Supplement #7 - Modification to the Required Beginning Date for Plan Participants
Tax Notice 2024
Alternate Payee Application for Benefits
Annual Certification Form (65-70½)
Annual Certification Form (Under 65)
Basic Pension Application
Direct Deposit Form
Federal Income Tax Withholding Form
State Tax Withholding Form
401(k) Contribution Limit Changes for 2025
Contribution Payment Methods
Managing Contribution Benefits
401(k) Enrollment/Change/Opt-Out Form
Corporate Officer Sole Proprietor Election to Participate
Designation of Exempt Owner
Inactive Status Request Form
Benefit information varies by Trust Funds. Please make a selection.
