UFCW & Employers Benefit Trust Forms

• Adopted/Step Child Verfication Form.pdf
• Appointment of Personal Representative Form.pdf
• Authorization to Release Information Form.pdf
• CA State Disability Form
• Change of Contact Information Form.pdf
• Disabled Dependent.pdf
• Dismemberment & Loss of Sight Form.pdf
• Domestic Partner Declaration of Dependency Form.pdf
• Extended Medical Benefits.pdf
• informedRX Drug Reimbursement Form.pdf
• informedRx Mail Order Form (Retirees Only).pdf
• Kaiser Medical Co-Pay Reimbursement Form.pdf
• Medical Claim Form.pdf
• Military Return Form.pdf
• UEBT Butchers Student Certification Form.pdf
• UEBT Sick Leave/Disability Extension Form.pdf
• UEBT Student Certification Form.pdf
• UEBT Chiropractic/Acupuncture Claim Form (HMO Only).pdf
• UEBT Extended Death.pdf

Pension Forms

• Direct Deposit Form.pdf
• Pension Credit Inquiry Form.pdf
• Withholding Election Form.pdf