Forms

ACH Request Form for Short Term Disability

Allocation of Reciprocal Contributions

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 2020 Form

Opt-Out EOB Form

Participant Consent Form

Self-Contribution Reimbursement Form

VSP Out-Of-Network Reimbursement Form

2020 1st Time User Instructions for Health Risk Assessment

2020 Returning User Instructions for Health Risk Assessment