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FORMS
NOTE: These forms are all in PDF format. You
must have Adobe Acrobat Reader installed on your computer. If you cannot open
these files, please go here and download Acrobat
Reader for free.
Claims for Dental,
Vision, Disability, Health Club, and Flu Shot are
to be sent to the address on the form for reimbursement. Please make a copy for
your records.
Dental Form
Vision Form
Dental & Vision Benefits Page
Insurance Update
Form
H&W /
SASMI Beneficiary Forms
PREVENTIVE CARE FORMS
Disability Form
Flu Shot Form
Health Club
Student Verification H&W Form
Health & Welfare Enrollment Form
Mail Order
Prescription Forms (Right Source -Phone# 1-800-379-0092)
Deductible Reimbursement Benefit Claim Form
RETIREE'S FORMS
Pension form to be
sent to address on the first page at the bottom and do not forget to mark
whether the application is for Vesting or
Retirement purposes.
Pension Vesting Form
401h Monthly Medicare Benefit
SASMI Severance Form
SASMI Health & Welfare Benefit Direct Payment Form
If you would like your
dues paid automatically every month from your credit union account, please fill
this out and send to Beacon Credit Union
Beacon Credit Union Automatic Draft (for dues payment)
This form can be filed
after regular filing period has ended. Please make sure that you send a copy of
your unemployment print-out for the last 90 days and send it back to
the Hall for proper processing.
(Remember you must
be unemployed for 90 consecutive days in order to receive the benefit.)
Emergency SASMI Form
]SASMI
Addendum to file H&W Payments (if eligible)
Addendum
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