• YOU ONLY NEED TO PRINT & COMPLETE PAGE 1 ONLY. THEN MAIL THE FORM ALONG WITH YOUR PHARMACY RECEIPTS  DIRECTLY TO BLUE CROSS BLUE SHIELD OF KS AT ADDRESS LISTED ON THE FORM, NOT THE FUND OFFICE!!!

Vision Form

This form must be downloaded & printed. Then complete the sections indicated on the form completed, and send it to the above address along with:

• an itemized statement of charges from the provider of the vision services (breaking down each charge for exam, lenses, frames, and contacts), and

• a copy of your lens prescription (if contacts or glasses were purchased).

Disability Form
Download & print both pages, complete page 1, and have your physician complete page 2 before sending both pages to our office. Download: Page 1 & Page 2

Health & Welfare Subscriber Update Sheet - This form is used for adding or deleting dependants.   If you  get married, divorced, or have a child, this is the form that needs to be completed & mailed to the Fund Office.  Supporting documentation must accompany this sheet (i.e. marriage license, divorce decree, etc.). 
 

BLUE CROSS & BLUE SHIELD WILL NOT ADD A DEPENDENT WITHOUT OUR OFFICE NOTIFYING THEM AND SENDING THEM A COPY OF THIS FORM.

• Notice of Termination of Employment  - (not available for download - you must call or write to C&J Benefit Solutions, Inc. to have a Form mailed to you)
• Notice of Retirement or Disability - (not available for download - you must call or write to C&J Benefit Solutions, Inc. to have a Form mailed to you)

Local 441 Plumbers and Pipefitters Retirement Plan (LP)

If you have questions about this Plan or need assistance, call Joe Pucci at (620) 232-3799

• Designation (or change) of Beneficiary for Pre-Retirement Death Benefit
• Emprise Bank Direct Deposit Form
• Local Pension Federal Withholding Certificate
• Local Pension Kansas Withholding Certificate

*  Details regarding the benefits and rules of the H&W Plan and Pension Plans are contained in the Summary Plan Description (SPD) for the Plan(s)