Insurance & Pension

Insurance and Pension Forms

Doctor & Hospital Finder www.bcbs.com
go to BlueCard Doctor & Hospital Finder

Health & Welfare Forms

Loss of Time Form (Disability)	Loss of Time Continuation Form
Enrollment Information Change Form	Student Verification Form
Prescription Drug Form	Dental Claim Form
Dental Claim Form (Ortho)	Vision Claim Form
Designation of Beneficiary Card	Request for Extension of Basic or Major Medical Benefits
Health & Welfare General Appeals

Pension Forms

Application for Pension Benefit	Retirement Declaration Form
Joint & 50% Surviving Spouse	Federal Tax Withholding Letter (W4-P)
Direct Deposit of your Pension Benefit (EFT)	Reemployment Questionnaire
Application for Disability Benefit

If you have any questions please feel free to call and speak with the Insurance & Pension Department
(502)368-5885 or call Central States Insurance and Pension Funds @ 1-800-323-5000
www.centralstatesfunds.org