Health and Welfare Fund – Forms/Notices

Due to the “stay-at-home” mandate as a result of COVID-19 and to protect our members and Fund Office staff, members must call the Fund Office first and refrain from visiting the Fund Office.  All non-essential appointments are either being handled through a  phone call or re-scheduled to a later date.  If you need any documents notarized, please read the Executive Order signed by Governor J.B. Pritzker. Thank you for your patience and understanding.

FORMS – If you are unable to access any of the following forms, please contact the Fund Office to request the specific form(s) you need.

Reciprocity

• Transfer Forms

Change of Address

If you recently moved, please login to your www.My150.com account to easily update your address by clicking on your My Profile.  By updating your address on My150 all Local 150 entities will be notified of your updated address (i.e., District Office, Apprenticeship Training, Fund Office, etc.). Alternatively, you can complete the following Change of Address Form and submit the form to the Fund Office.

• Change of Address Form

OHC Forms

• Flu Shot Form

VOYA Financial

The following form is used to update the MCL $10,000 basic death benefit (for members only) and for the Supplemental Life Insurance.  Once the form is completed, please mail to:

Kocher Insurance Group, Inc.
ATTN: Will McCabe
1165 N. Clark Street, 7th Floor
Chicago, IL 60610

• VOYA Beneficiary Designation Form

Welfare Fund Forms

• Welfare Fund Appeal Request Form
• Accidental Dismemberment Benefit Claim Form
• Active Employee Death Benefit Beneficiary Designation Form
• Verification of Dependent Handicapped Child Form
• Disability Claim Instructions and Forms
• Health and Welfare Claim Form
• Family Supplemental Claim Form
• Changes to Privacy Notice and Forms/Personal Representative Form – please update your PHI pin through My150 (www.my150.com)
• If you do not have a My150 account, please click here and complete the attached Personal Representative Form to update your PHI pin
• Retiree Medical Savings Plan (RMSP) Claim Form
• Retiree Medical Savings Savings Plan (RMSP) Beneficiary Form – Please submit this information to the Member Services Department at the Fringe Benefit Funds Office

Miscellaneous Forms

• Dependent Enrollment Form
• Adult Dependent Enrollment Form
• Employment and Prior Healthcare Questionnaire
• Custodial Parent Questionnaire

 NOTICES

• Nondiscrimination Notice Under Section 1557 of the Affordable Care Act

Welfare Fund Notices

• Annual Breast Reconstruction Notice & Notice of Creditable Coverage
• Summary Annual Report as of March 31, 2019
• ACA Requirements Applicable to Large Employers/Associations