Sunday, December 21, 2014


Sheet Metal Workers Union Local 104

Member Fringe Benefit Website

Health Care Plan Information

Please use the site menu to navigate to detailed information on the summary plan description. For general health related frequently asked questions (FAQs) and links, please see information on this page! 

If you have any questions or would like clarification, you can request additional information by calling the Benefit Fund Office. Your questions may be referred to the Board of Trustees.

Health Care Links  Health Care Links

Health Care Documents  Health Care Documents
Kaiser Permanente Enrollment Form Download
HIPAA Privacy Instructions and Form Download
Medical Claim Form - DisabilityDownload
Envision Pharmacy Direct Claims Download
Envision Pharmacy Coordination of Benefits Download
Address Verification Change Form Download
Benny Card FAQ Download
Benny Card Introduction LetterDownload
Benny Card IIAS Merchant ListingDownload
Benny Card Changes as of July 1, 2009Download
HRA FormDownload
** NEW** Enrollment Form for Dependents Ages 19-25Download
** NEW ** Summary of Material Modification - Annual Maximums and Dependents Ages 19-25 CoverageDownload
** NEW ** 2009-2010 Summary Annual ReportDownload
** NEW ** Preventive Services Covered Under the Affordable Care ActDownload
VSP Summary of BenefitsDownload
Delta Dental PPO Summary of BenefitsDownload
Kaiser Chiropractic Provider Directory 2011Download
Kaiser Summary Benefit - Actives & Early RetireesDownload
Kaiser Summary Benefit - Senior AdvantageDownload
Blue Shield Reimbursement Form Download
2013 HRA Annual and Interest Allocation NoticeDownload
Kaiser Benefit Summary - Actives (9-1-13 - 8-31-14)Download
Kaiser Benefit Summary - Early Retirees (9-1-13 - 8/31/14)Download
Benefit Summary - Senior Advantage with Part D (9-1-13 - 8-31-14)Download
Kaiser Summary of Benefits Coverage - Actives - 9/1/13 - 8/31/14Download
Kaiser Summary of Benefits Coverage - Early Retirees - 9/1/13 - 8/31/14Download
Enrollment Form Download
Statement of Medical Claim Download

Health Care FAQs  Health Care FAQs

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