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

How to Access Verification Only 2021 via the Member Dashboard

MD 2021 Form

Opt-Out EOB Form

Participant Consent 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