Beneficiary Form
Change of Address
General Authorization Form
General Authorization Cancellation Form
Dental Enrollment Form (For those who have not yet made an election)
Disenrollment Form
Enrollment Form
HRA Reimbursement 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
Dental Enrollment Form (During Open Enrollment only)
Weekly Disability Notice of End of Total Disability
Annual Coordination of Benefits Form
Injury and Third Party Liability Form
Summary Plan Description - Nov 2019
Supplement #1 - Nov 2019 (Establishing, Re-establishing and Maintaining Eligibility)
Supplement #2 - Nov 2019 (Re-establishing Eligibility)
Supplement #3 - Nov 2019 (Transition Employee Program)
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)
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 #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 #13 - Feb 2021 (COVID-19 Vaccinations)
Supplement #14 - May 2021 (COBRA 100% Premium Assistance and the Subsidized Self-Pay Program)
Summary of Benefits & Coverage 2023
Glossary of Health Coverage & Medical Terms - 2021
Glosario de terminos medicos y seguros de salud - 2021
VSP Grievance Process and Timely Access to Care Notice
VSP Member Benefits Summary
Delta Dental PPO Benefits Summary of Evidence of Coverage (Effective September 1, 2018)
DeltaCare USA DHMO Benefits Summary
Supplement #19 - Aug 2021 (High Cost Medication)
Supplement #20 - Dec 2021 (Protections Against Balance Billing Under the No Surprises Act)
Supplement #21 - Feb 2022 (COVID-19 Testing)
Notice of Privacy Practices
Annual Medicare Part D Notice
HRA Benefits Mobile App Guide
HRA Benefits Portal Guide
Your Rights And Protections Against Surprise Medical Bills
Supplement #22 - May 2022 (Establishing, Re-Establishing, And Maintaining Eligibility)
Supplement #23 - June 2022 (Dependent Child Special Disability Benefits)
Telemedicine Programs
Overview for New Participants
Supplement #24 - May 2023 (COVID-19 Testing and Vaccinations)
Surviving Spouse Medical Dental & Vision Enrollment Form
2022 Dental Enrollment Form (During Open Enrollment Only)
2022 Vision Enrollment Form (During Open Enrollment Only)
Annual Statement of Employment by Pensioner (Over Age 70 ½)
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 #8 - Jan 2021 (COVID-19 Vaccinations)
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
DeltaCare USA Medium Benefit Summary
Supplement #14 - Feb 2022 (COVID-19 Testing)
Supplement #15 - Dec 2022 (2023 Monthly Premiums)
Supplement #16 - May 2023 (COVID-19 Testing and Vaccinations)
VSP Grievance Process And Timely Access To Care Notice
Certification of Termination of Employment
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
Termination Distribution Application
Special Notes Regarding Hardship Withdrawals
Termination Distribution for Non-Covered Employment
Certification of Termination of Covered Employment and Transition to Non-Covered Employment with an Employer
Loss of Income Verification
Fund Rollover Notice
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)
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)
Basic Pension Application
Direct Deposit Form
Alternate Payee Application for Benefits
2022 Annual Statement (Ages 65-70½)
2022 Annual Statement (Under 65)
Federal Income Tax Withholding Form
State Tax Withholding Form
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)
Annual Funding Notice 2014
Annual Funding Notice 2015
Annual Funding Notice 2016
Annual Funding Notice 2017
Annual Funding Notice 2018
Annual Funding Notice 2019
Annual Funding Notice 2020
Annual Funding Notice 2021
Supplement #4 - Sept 2022 (Pension Benefit Increase)
Supplement #5 - Dec 2022 (Proof of Total Disability)
Annual Funding Notice 2022
401(k) Enrollment/Change/Opt-Out Form
Inactive Status Request Form
Contribution Payment Methods
Managing Contribution Benefits
Benefit information varies by Trust Funds. Please make a selection.
