Forms

ACH Request Form for Short Term Disability

Allocation of Reciprocal Contributions

Appeal Form

Change of Address Form

Dependent Consent Form

Disability Form

Health & Welfare ULLICO Beneficiary Designation Form

Instruction Sheet for Filling Out ULLICO’s Designation of Beneficiary Form

HIPAA Form

MD 2021 Form

Opt-Out EOB Form

Participant Consent Form

Personal Representative Form

Self-Contribution Reimbursement Form

VSP Out-Of-Network Reimbursement Form

2021 1st Time User Instructions for Health Risk Assessment

2021 Returning User Instructions for Health Risk Assessment