Forms

 

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  • 2014 Plan 1 Open Enrollment Form

  • 2014 Plan 500 Open Enrollment Form

  • 2014 Plan 500 for Plan 1 Open Enrollment Form

  • 2014 Plan 1000 Open Enrollment Form

  • 2014 Coverage Rejection Form

  • Accident Injury Report Form

  • Authorization For Release Of Health Information By Employee

  • Beneficiary Card / Pension Forms / Retirement Forms

  • Family Member Application Survey Form

  • Single Member Application Survey Form

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    United Food and Commercial Workers Local 400 and Employers Health and Welfare Fund
    600 D Street, Suite 250
    South Charleston, WV  25303
    866.343.7682 Toll Free  •  304.343.7682 Phone  •  304.345.2832 Fax  •  ufcwl400hw_wv@juno.com Email

    SERVING - West Virginia  •  Kentucky  •  Ohio

    Copyright ©2013 http://www.ufcwl400healthandwelfare.org. All rights reserved.