Health & Welfare Forms & Notices

To view additional plan documents, you can visit your My150 and click on My LIBRARY

Forms

Accidental Dismemberment Benefit Claim Form
Active Employee Death Benefit Beneficiary Designation Form
Adult Child Enrollment Form
Change of Address Form
- If you recently moved, please login to your www.My150.com account to easily update your address by clicking on your My Profile. By updating your address on My150 all Local 150 entities will be notified of your updated address (District Office and Fund Office). Alternatively, you can complete this Change of Address Form and submit it to the Fund Office.
Changes to Privacy Notice and Forms/Personal Representative Form – please update your PHI pin through My150 (www.my150.com)
- If you do not have a My150 account, please click here and complete the attached Personal Representative Form to update your PHI pin
Disability Claim Instructions and Forms
Disabled Dependent Eligibility Review Form
Electronic Consent Form
Family Supplemental Claim Form
Health and Welfare Claim Form
Reciprocity Transfer Form
Retiree Medical Savings Plan (RMSP) Claim Form
Retiree Medical Savings Savings Plan (RMSP) Beneficiary Form
- Please submit this information to the Member Services Department at the Fringe Benefit Funds Office
VOYA Beneficiary Designation Form
- This form is used to update the MCL $10,000 basic death benefit (for members only) and for the Supplemental Life Insurance. Once the form is completed, please mail to: Kocher Insurance Group, Inc.
  ATTN: Will McCabe
  1165 N. Clark Street, 7th Floor
  Chicago, IL 60610
Welfare Fund Appeal Request Form

Notices

Benefits | Healthcare