Employees

General

• COBRA
• Enrollment Form
• Change of Status
• Coordination of Benefits
• Coordination of Benefits – Spanish
• Authorization Form
• Dental Claim Form
• Termination/COBRA Action
• Medical Claim Form
• Vision Claim Form
• Disability Claim Form
• Continuity of Care Application Form

Chicago Transit Authority (CTA) Retirees

• Address Change Form
• HRA Brochure (2017)
• HRA Claim Form
• HRA eligible medical list

Construction Industry Welfare Fund of Rockford (CIWFR)

• Incoming Reciprocity Form
• Outgoing Reciprocity Form
• Construction Fund Loss of Time
• Construction Fund Spousal Form
• Construction Fund Young Adult Form

Fox Valley and Lake County

• Fox Valley Lake County Hardship Withdrawal
• Fox Valley Lake County Retirement Withdrawal
• Fox Valley Lake County Beneficiary Designation
• Fox Valley Lake County Pension Application
• Fox Valley Lake County Pension Application (Spanish)
• Fox Valley Lake County Inservice Withdrawal
• Fox Valley Lake County Change of Address Form

Flexible Spending Account (FSA)

• • FSA Enrollment Form
  • FSA Medical Claim Form (Flex)
  • FSA Debit Card Instructions

Iron Workers Tri-State Welfare Fund

Beneficiary Designation Form
Express Scripts Claim Form
Disability Claim Form

Dependent Addition Request Form
HRA Claim Form
VSP Vision Claim Form
Reciprocity Election Form
Accident Information Request Form

Summary Plan Descriptions

SPD
Schedule of Benefits Locals 111, 112, 393, 444, 498
Local 380 Schedule of Benefits
Iron Workers Tri-State Welfare Fund 2021 SBC – Locals 111, 112, 393, 444, 498
Iron Workers Tri-State Welfare Fund 2021 SBC – Local 380

DEBIT CARD

Debit Card