PRINTABLE
FORMS
![j0297697[1]](forms_files/image003.gif)
|
|
Underlined forms are down
loadable and you will need Acrobat Reader to view and print them. If you do not
have it, I have placed the free download link below. Please set printer for
color for those forms that have the word (color) in parenthesis and remember
that these forms take long to appear, once they are opened, if you have
dial-up.
Affidavit of
Stolen/Lost Drug I.D. Card (color)
A DC 37 form to
be filled out by you and notarized to receive a duplicate Prescription drug
card within 21 days.
Authorization for Deduction of Dues
Form for newly hired employees to fill
out for the automatic deduction of union dues.
Beneficiary Designation
Any employee may change their
beneficiary listed, with their employer, at any time or for any reason.
Change of Beneficiary Card
A form you
fill out and sign in front of a Notary Public to change the recipient of your
death benefits.
Change of Status Card
DC 37
form you fill out to inform the
CFI Prescription Refills
up to a
90 day supply of prescribed drugs(generically or you pay the difference unless
not available in generic form) plus one refill for a one time co-payment of
Five dollars.
Dental Form-
Proposed Treatment or Statement of Claim
DC 37
form you and your Dentist fill out to approve work ahead of time or
reimbursement of such work.
Enrollment Card
The employee to establish benefits dependents
and beneficiaries with D.C. 37 fills out this card. A must for a per diem newly
converted to part-time status.
Medical Release Form
DC
37 Health and Security Plan form to allow the union to release medical
information to assist in claims.
Short-Term Disability Benefit Claim
A DC 37 form you and your doctor fill
out after sustaining an injury or illness, that will prevent you from working
for an extended period of time, and before returning to work.
Claims received by DC
37 are frequently delayed or returned because they are incomplete. Your
claim may be delayed or returned Unless you do the
following:
- Sign your name.
- Give the phone number of your time
keeper/payroll/personnel department.
- Describe your illness.
- Indicate if you were hurt at work.
- Indicate if there is a lawsuit- if so, indicate
the Attorneys' name, address and telephone number.
- Make certain your social security number is
correct.
- Enclose a copy of your
Marriage/Divorce/Separation papers if you have changed your name.
- Attach an explanation to your claim if it is
filed 15 or more days after the onset of your disability.
- You must have a DC 37 Health and Security Plan
Enrollment Card on file.
The Physicians
Statement side of the claim form is to be entirely completed and only
by your doctor.
You should not complete
or alter any of the information in this section. Check particularly to be sure
that your doctor includes dates of all treatments and expected duration of your
disability.
If you leave the claim
with your doctor, have it mailed to you before submitting so you can check for
completeness.
Starting
Gate | About | Contact | Site
map | Awards | City-Wide
Contract | 2021 Officers | 2021
Alerts |
| News
from 2021 | 2021 Meetings | City-Wide
Health Plans | DC 37 Officers| DC
37 Dental Plan |
| DC 37 Prescription Plan | DC
37 Vision Plan | DC 37 Legal Service | Printable Forms |
|
All Other Benefits | Website
Links |
