Forms & Notices

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Pension

Health

Dental

Delta Dental PPO Certificate

Summary of All Plans

Benefits at a Glance – March 1, 2022

Delta Dental and Orthodontics

Delta Dental GRIN

Disability

Authorization For Release of Information to Local 8

Authorization For Release of Information Form

Total & Permanent Disability Application

Short Term Disability Claim Form

Disability Short Term & Permanent Brochure

Definition of Total and Permanent Disability

Continuation of Benefits Form

Life Insurance

Summary of Coverage for Active Members – December 2008

Beneficiary Designation Form

Group Term Life Benefit Certificate – January 2017

Rx/Prescription Drug Coverage

Express Scripts Pharmacy Mail Order Form

Accredo-Express Script Specialty Pharmacy Brochure

Accredo Specialty Drug List

Express Scripts Preferred Rx and Exclusion List

Express Scripts Rx Reimbursement Form

Summary of Material Modifications RX – September 2020

Summary of Material Modification Effective 6/1/2018

Prescription Benefit Change Effective November 2020

Summary Annual Reports

2022 Health Plan Summary Annual Report

2021 Health Plan Summary Annual Report

2020 Health Plan Summary Annual Report

2019 Health Plan Summary Annual Report

2018 Health Plan Summary Annual Report

2017 Health Plan Summary Annual Report

2016 Health Plan Summary Annual Report

2015 Health Plan Summary Annual Report

2014 Health Plan Summary Annual Report

Vision and Hearing

Amplifon Hearing Program – Effective 7/1/2020

Low Vision Benefit

EyeMed Benefit Summary – Effective 7/1/2020

Eye Med – FAQ’s

EyeMed – Mobile App – How to Use

EyeMed Safety Glasses

Freedom Pass Special Savings Program

Out-of-Network Vision Claim Form

Health & Welfare

ACH Authorization / Direct Deposit Form

ACH Authorization / Direct Deposit (FILLABLE)

Change of Address Form

COBRA Initial Notification of Rights

Dialysis Benefit Brochure

Email Opt In Form – November 2012

ENROLLMENT FORM 2024

Spousal Affidavit

Application for Surviving Spouse

HIPAA Authorization Form

Insurance Reimbursement Claim Form

Non-Discrimination Notice

Accident Questionnaire

Out of Network Case Management Protocols

SupportLinc Flyer

Surviving Spouse Waiver of Insurance

Policy for Spouses with Other Health Coverage

Your Privacy Rights Under HIPAA

Suicide Prevention

I Am Mentally Healthy

It’s Okay to Feel

How to Help a Coworker in Distress

Suicide Prevention in the Workplace for Managers

Suicide Prevention in the Workplace

Summary Plan Description

Summary of Benefits Brochure – Active Plan

Summary of Benefits Brochure – Base Plan

Summary of Benefits and Coverage – Plan A (Actives) – January 2024

Summary of Benefits and Coverage – Plan B (Base Benefits) – January 2024

Summary Plan Description for Plans A, B, R, & M – January 2020

VEBA-SFBF

Travelers Basic VEBA Information

SFBF/VEBA Deadline for Claim Submittal

ACH Authorization / Direct Deposit Form (WRITABLE)

Automatic Reimbursement Election Form

Dependent Care Reimbursement Information

Educational Tuition/Book Reimbursement – January 2014

How to Navigate on Website for SFBF/VEBA

Mileage Reimbursement Instructions – March 2013

Mileage Rates for VEBA

Prescription Notice – September 2012

SFBF New Benefit – Type I & Type II – January 2005

SFBF/VEBA Main Claim Form

SFBF/VEBA Claim Form — Additional Page

SFBF/VEBA Reimbursement Schedule

VEBA Basic Information

VTL Insurance

Mutual of Omaha Voluntary Life Insurance Check List

Voluntary Term Life Insurance Summary of Coverage – June 2009

Voluntary Term Life Insurance Summary of Benefits

Voluntary Term Life Insurance Enrollment Form

Voluntary Term Life Conversion Coverage Form

Voluntary Term Life Insurance Evidence of Insurability Form

Voluntary Term Life Insurance Certificate Summary

Voluntary Term Life Insurance Group Benefits – January 2019

Mutual of Omaha VTL Beneficiary Form

Mutual of Omaha VTL Brochure – April 2009

Mutual of Omaha Rate Table

Mutual of Omaha VTL EFT Form

Retirement

Rx/Prescription

Express Scripts Pharmacy Mail Order Form

Express Scripts Rx Reimbursement Form

Accredo-Express Script Specialty Pharmacy Brochure

Accredo Specialty Drug List

Prescription Drug Coverage and Medicare Notice

2023 TEWF EGWP Medicare D Formulary

Medicare Part D Creditable Coverage Notice

Summary Plan Description

Summary of Benefits and Coverage – Plan R (Early Retirees) – January 2023

Summary of Benefits and Coverage – Plan M (Medicare Supplement) – January 2023

Summary Plan Description for Plans A, B, R, & M – January 2020

Summary of Benefits Brochure – Normal Retiree

Summary of Benefits Brochure – Early Retiree

General

Application for Retirement – April 2011

Early Retiree Opt Out Request for Reimbursement

Retiree Checklist for Health & Welfare – January 2018

Beneficiary Designation Form

Alternate Coverage Waiver Form – January 2014

Retiree Opt Out Program – January 2023

Retirement Check List – Pension – April 2010

401(k)

Notices

IBEW Local No. 8 IBEW Retirement Plan and Trust SPD

Summary of Material Modification – January 2017

Forms

401k Distribution Form

In-Service Distribution Form

Hardship Form

Summary Annual Reports

2016 401K Summary Annual Report

2015 401K Summary Annual Report

2014 401K Summary Annual Report

2013 401K Summary Annual Report

2012 401K Summary Annual Report

2011 401K Summary Annual Report

2010 401K Summary Annual Report

2009 401K Summary Annual Report

2008 401K Summary Annual Report

2007 401K Summary Annual Report

2006 401K Summary Annual Report

2005 401K Summary Annual Report

2004 401K Summary Annual Report

Eligibility / Self-Payments

Eligibility and Self Payment Guide – January 2021

Self-Payment Authorization Form

Waiver of Self Pay & FAQ

Eligibility and Self Payment FAQs – March 2021

Self Pay/Eligibility Chart

Retirement Self-Payment Schedule 2023

COBRA Subsidy

COBRA Premium Assistance FAQS
American Rescue Plan Assistance Request Form
Extended Election COBRA Notice Form