Beneficiary Form
Change of Address
General Authorization Form
General Authorization Cancellation Form
Weekly Disability Notice of End of Total Disability
Injury and Third Party Liability Form
Annual Coordination of Benefits Form
Weekly Disability Continuation Form
Weekly Disability Application
Vision Enrollment Form (For those who have not yet made an election)
Prescription Drug Claim Form
PHI Request Form
HRA Reimbursement Form
Enrollment Form
Disenrollment Form
Dental Enrollment Form (For those who have not yet made an election)
Dental Enrollment Form (During Open Enrollment only)
Annual Medicare Part D Notice
Notice of Privacy Practices
Supplement #21 - Feb 2022 (COVID-19 Testing)
Supplement #20 - Dec 2021 (Protections Against Balance Billing Under the No Surprises Act)
Supplement #19 - Aug 2021 (High Cost Medication)
HRA Benefits Mobile App Guide
DeltaCare USA DHMO Benefits Summary
Supplement #28 - September 2024 (Nutritional Counseling)
Supplement #29 - September 2024 (Substance Use Disorder Treatment)
Supplement #31 - November 2024 (Eligible Dependent)
Supplement #30 - November 2024 (Off-Label Prescription Medication)
Supplement #27 - June 2024 (Occupational and Speech Therapy)
Supplement #26 - September 2023 (MetLife Dental PPO Replacing Delta Dental PPO Option)
Supplement #25 - September 2023 (Colorectal Cancer Screening)
Supplement #24 - May 2023 (COVID-19 Testing and Vaccinations)
Overview for New Participants
Telemedicine Programs
Supplement #23 - June 2022 (Dependent Child Special Disability Benefits)
Supplement #22 - May 2022 (Establishing, Re-Establishing, And Maintaining Eligibility)
Your Rights And Protections Against Surprise Medical Bills
HRA Benefits Portal Guide
Supplement #3 - Nov 2019 (Transition Employee Program)
Supplement #16 - May 2021 (Out-of-Pocket Maximum)
Supplement #15 - May 2021 (Subsidized Self-pay Program Eligibility Rules)
Supplement #12 - Dec 2020 (Pain Management Benefits)
Supplement #11 - Oct 2020 (Vacation & Holiday Benefit Plan Improvements)
Supplement #10 - Oct 2020 (Clarification of Benefit for Cosmetic Surgery)
Supplement #9 - Sept 2020 (Hospital Services for Dental Procedures)
Supplement #8 - Sept 2020
Supplement #7 - Jul 2020 (Changes in Contribution Rates)
Supplement #6 - Jun 2020 (Merger of the Vacation & Holiday Fund into the Health & Welfare Fund)
Supplement #5 - Mar 2020 (COVID-19 Testing)
Supplement #4 - Mar 2020 (New Vision Benefit)
Supplement #17 - May 2021 (Clarification of Covered Providers for Mental Health Services)
Supplement #2 - Nov 2019 (Re-establishing Eligibility)
Supplement #1 - Nov 2019 (Establishing, Re-establishing and Maintaining Eligibility)
Summary Plan Description - Nov 2019
MetLife PPO Benefits Summary (Effective October 1, 2023)
VSP Member Benefits Summary
VSP Grievance Process and Timely Access to Care Notice
Glosario de terminos medicos y seguros de salud - 2021
Glossary of Health Coverage & Medical Terms - 2021
Summary of Benefits & Coverage 2025
Supplement #14 - May 2021 (COBRA 100% Premium Assistance and the Subsidized Self-Pay Program)
Supplement #13 - Feb 2021 (COVID-19 Vaccinations)
Supplement #18 - May 2021 (Establishing, Re-establishing, and Maintaining Eligibility)
Supplement #16 - May 2023 (COVID-19 Testing and Vaccinations)
Supplement #14 - Feb 2022 (COVID-19 Testing)
Supplement #15 - Dec 2022 (2023 Monthly Premiums)
DeltaCare USA Medium Benefit Summary
VSP Grievance Process And Timely Access To Care Notice
Supplement #17 - September 2023 (Colorectal Cancer Screening)
Supplement #18 - September 2023 (New Dental PPO Option)
Supplement #19 - November 2023 (Change in 2024 Monthly Premiums)
MetLife PPO Benefit Summary
Supplement #20 - June 2024 (Occupational and Speech Therapy)
Supplement #23 - November 2024 (Off-Label Prescription Medication)
Supplement #24 - November 2024 (Change in 2025 Monthly Premiums)
Supplement #21 - September 2024 (Nutritional Counseling)
Supplement #22 - September 2024 (Substance Use Disorder Treatment)
Supplement #8 - Jan 2021 (COVID-19 Vaccinations)
Supplement #1 - Nov 2019 (Recalculation Premium Score)
Supplement #2 - Nov 2019 (Change in 2020 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 #9 - June 2021 (Eligibility Rules)
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)
DeltaCare USA High Benefit Summary
Annual Statement of Employment by Pensioner (Over Age 70 ½)
Surviving Spouse Medical Dental & Vision Enrollment Form
Dental Enrollment Form (During Open Enrollment Only)
Vision Enrollment Form (During Open Enrollment Only)
Fund Rollover Notice
Special Notes Regarding Hardship Withdrawals
Termination Distribution for Non-Covered Employment
Certification of Termination of Non-Covered Employment
Loss of Income Verification
Terminal Illness Withdrawal Application
Qualified Disaster Recovery Distribution Application
Termination Distribution Application
Death Benefit Application
DC Fund Enrollment/Change/Opt Out Form
Hardship Withdrawal Application
Home Repair Option Supplemental Form
Payment Due to QDRO Application
Qualified Birth Adoption Withdrawal
Retirement Declaration Form
Retirement/Disability Distribution Application
Special Employer Account 401(a) Withdrawal Application
Certification of Termination of Employment
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)
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)
Interim Withdrawal Form
V&H Monthly Benefit Election Direct Deposit Form
V&H Normal Benefit Election Direct Deposit Form
Supplement #1 - Jun 2020 (Merger of the Vacation & Holiday into the Health & Welfare Fund)
Annual Funding Notice 2017
Supplement #6 - Dec 2024 (Modification of the Post-Retirement Civil Service Employment Rule for Pensioners under Age 70½)
Annual Funding Notice 2023
Tax Notice 2024
Annual Funding Notice 2022
Supplement #5 - Dec 2022 (Proof of Total Disability)
Supplement #4 - Sept 2022 (Pension Benefit Increase)
Annual Funding Notice 2021
Annual Funding Notice 2020
Annual Funding Notice 2019
Annual Funding Notice 2018
Annual Funding Notice 2016
Annual Funding Notice 2015
Annual Funding Notice 2014
Supplement #3 - May 2021 (Pension Benefit Accrual Rate Increase)
Supplement #2 - Jul 2020 (Changes in Contribution Rates)
Supplement #1 - Nov 2019 (Modification in Suspension of Benefits Age 65 or Older)
Annual Certification Form (Under 65)
Annual Certification Form (65-70½)
State Tax Withholding Form
Federal Income Tax Withholding Form
Basic Pension Application
Alternate Payee Application for Benefits
Direct Deposit Form
401(k) Enrollment/Change/Opt-Out Form
Inactive Status Request Form
Designation of Exempt Owner
Corporate Officer Sole Proprietor Election to Participate
Contribution Payment Methods
Managing Contribution Benefits
401(k) Contribution Limit Changes for 2025
Benefit information varies by Trust Funds. Please make a selection.
