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Dependent Enrollment Form Use this form to enroll your dependents for dental and vision benefits or make changes in type of coverage (as allowed by the Plan). CLICK TO DOWNLOAD FILE 2010 Dental Brochure This brochure provides a brief overview of dental benefits. This dental brochure gives the premiums for member's dependent coverage for both the dental and vision benefit plans. CLICK TO DOWNLOAD FILE Dental Reimbursement Form You may attach your dentist's itemized receipt to the form or have your dentist complete and submit. CLICK TO DOWNLOAD FILE Davis Vision--Out-of-Network Use this form to request reimbursement for sevices received from providers who do not participate in the Davis Vision network. CLICK TO DOWNLOAD FILE 2010 Davis Vision Brochure This brochure describes the vision benefits offered by Davis Vison (www.davisvision.com) CLICK TO DOWNLOAD FILE FSA -- 2009-10 Dependent Care Reimbursement Use this claim form to submit eligible dependent care expenses incurred between September 1, 2009 and August 31, 2010. A separate claim form is required for each member of your family. CLICK TO DOWNLOAD FILE FSA - 2009-10 Medical Reimbursement Request Please complete this document and attach support materials. Send this reimbursement request to the Fund office. CLICK TO DOWNLOAD FILE Beneficiary Designee Card Use this form to designate your beneficiary(ies) for your premium free life insurance benefit. CLICK TO DOWNLOAD FILE FSA -- 2010-11 Medical Enrollment/Agreement Original enrollment and salary reduction agreement must be received by the Fund office by August 31, 2010. A faxed or emailed copy of the agreement will not be accepted. CLICK TO DOWNLOAD FILE FSA -- Medical Care Worksheet Use this worksheet to assist you in estimating your annual medical care expenses. It may help you decide if you want to elect to participate in the Medical Care Flexible Spending Account. CLICK TO DOWNLOAD FILE FSA -- 2010-11 Medical Care Reimbursement Request Use this claim form to submit eligible medical care expenses incurred between September 1, 2010 and August 31, 2011. A separate claim form is required for each member of your family. CLICK TO DOWNLOAD FILE FSA -- 2010-11 Guidelines--Medical Claim To enable the Fund office to properly process your FSA Medical Claim, the correct documents and information must be provided. These guidelines will assist you in the preparation of the claim form. CLICK TO DOWNLOAD FILE FSA -- 2010-11 One-Time Dental Authorization If you have a FSA medical care account, use this form to process any out-of-pocket dental expenses. CLICK TO DOWNLOAD FILE FSA -- 2010-11 Dependent Care Enrollment/Agreement Original enrollment and salary reduction agreement must be received by the Fund office by August 31, 2010. A faxed or emailed copy of the agreement will not be accepted. CLICK TO DOWNLOAD FILE FSA -- Dependent Care Worksheet Use this worksheet to assist you in estimating your annual dependent care expenses. It may help you to decide if you want to elect to participate in the Dependent Care Flexible Spending Account. CLICK TO DOWNLOAD FILE FSA--2010-11 Dependent Care Reimbursement Request Complete this document and attach support materials. Please send the original copies to the Fund office before August 31, 2011. CLICK TO DOWNLOAD FILE FSA -- 2010-11 Guidelines--Dependent Care To enable the Fund office to process your FSA dependent care claim, the correct documentation and information must be provided. These guidelines will assist you in the preparation of the form. CLICK TO DOWNLOAD FILE 2010 JFTHW Privacy Notice This notice provides information on Protected Health Information. CLICK TO DOWNLOAD FILE 2010 PHI Authorization Form Completion of this document gives another individual access to your protected health information. CLICK TO DOWNLOAD FILE 2010 PHI Revocation Form Completion of this document removes this person from accessing your protected health information. CLICK TO DOWNLOAD FILE FSA -- 2009-10 One-Time Dental Authorization If you have the Medical Care FSA for Plan Year 09/01/09 - 08/31/10, use this form to permit processing any out-of-pocket dental expenses through your Medical Care Account CLICK TO DOWNLOAD FILE DISCLAIMER | HOME