Welfare Plan Form Downloads
Download and access important Welfare Plan forms below. If you need further assistance please call us at: (708) 449-7373.
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Annual Coordination of Benefits Form
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Retiree Self-Payments Effective March 1, 2025
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Benefit Enrollment Form
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Universal Beneficiary Designation (UBD) Form
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Universal Beneficiary Instructions
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HIPAA Authorization Form
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Change of Address
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Weekly Direct Deposit Form
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Weekly Disability Initial Form
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Weekly Disability Continuation Form
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Weekly Maternity Benefit
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Hearing Aid Benefits Claim Form
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Delta Dental of Illinois Form
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EyeMed Out of Network Vision Claim Form
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Major Medical
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Personal Representative Form
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Discrimination is Against the Law
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Language Assistance Services - Foreign Languages
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Express Scripts Claim Form
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MCM - New Living Well Disease Management
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SMM - RSV Vaccine - Retiree Plan
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SMM - RSV Vaccine - Plan A, Plan C Bargained & Plan C Staff