7706 Maltlage Drive, Liverpool, New York 13090, United States

(315) 699-1808

FUND OFFICE RELATED FORMS AND DOCUMENTS

You can easily download any of the forms you need and print them at home to be completed and returned to the Fund Office. 


 For any documents that you do not see listed here or for any other Fund Office related information, please email us at 195funds@rooferslocal195.com
or call us at (315) 699-1388 M-F 8:30am to 4:30pm 

Health Related Enrollment and Claim forms

Aetna Enrollment Form (pdf)

Download

Individual Account Claim (IAP) Form (pdf)

Download

AETNA RX Home Delivery Medication Order Form (pdf)

Download

IAP Claim Workbook (Helps you to calculate & organize your receipts (xlsx)

Download

Supplemental Disability Allocation Form (pdf)

Download

Appeals of Adverse Determination (pdf)

Download

pRIMARY, SECONDARY & SPOUSAL INSURANCE INFORMATION FORMS

SPOUSE INSURANCE INFORMATION REQUEST FORM (pdf)

Download

Spousal Insurance Option Election-Rejection Form (pdf)

Download

Adult Dependent Enrollment Certification Form (pdf)

Download

Dependent Child Coordination of Benefits Form (pdf)

Download

rELEASE OF INFORMATION FORMS

Personal Representative Authorization (pdf)

Download

Notice of Privacy Policy (pdf)

Download

mISCELLANEOUS fORMS

Dental & Vision Benefits Termination (pdf)

Download

pARTICIPANT'S dESIGNATION OF bENEFICIARY fORMS

Designation Beneficiary Forms Plus Instructions (pdf)

Download

Pension Verification Update Letter (pdf)

Download

Summary Plan Description Booklets

Health Accident Fund Summary Plan Description (pdf)

Download

Pension Fund Summary Plan Description (pdf)

Download

Annuity Fund Summary Plan Description (pdf)

Download

Summary of Health Benefits & Coverage (pdf)

Download