Forms


INSURANCE 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.

Delta Dental

Vision Form

Insurance / Beneficiary Update Forms

PREVENTIVE CARE FORMS

Member Assistance Information

Disability Form

Flu Shot Form

Health Club

Mail Order Prescription Forms (Express Scripts)

Deductible Reimbursement Benefit Claim Form

Benny Card Reimbursement Claim Form

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Humana Medicare Advantage Enrollment Form

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PENSION 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 or Retirement  Application

Pension Re-Activation Form

401 H Medicare Subsidy Application

Pension Deduction Change Form

SASMI Severance and Health & Welfare HCRAA Form

SASMI Subsidy Form

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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)

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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

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SASMI Addendum to file H&W Payments (if eligible)

Addendum