Forms

ACH Request Form for Short Term Disability

Allocation of Reciprocal Contributions

Appeal Form

Change of Address Form

Consociate Portal Quick Start Guide

Dependent Consent Form

Disability Form

Health & Welfare ULLICO Beneficiary Designation Form

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

HIPAA Form

MedOne – Direct Member Reimbursement Form

Wellness Program Physician Form 2023

Opt-Out EOB Form

Participant Consent Form

Personal Representative Form

Self-Contribution Reimbursement Form

VSP Out-Of-Network Reimbursement Form