Roofers Local #195 

Fund Office


Health Related Enrollment and Claim Forms

Aetna Group Enrollment Form

Individual Account Plan Claim Form 

IAP Claim Workbook (Helps you to Organize Your Receipts)



AETNA RX Drug Claim Form

Appeals of Adverse Benefits Determinations


Primary, Secondary and Spousal Insurance Information Forms

Coordination of Benefits Questionaire & Spousal Insurance Information Form

Spousal Insurance Opt-Out Form

Spousal Insurance Option Election/Rejection Form

Adult Dependent Enrollment Certification Form

Dependent Child Coordination of Benefits Form

Release of Information Forms

Roofers Fund Office - Appointment of Personal Representative Form

HIPPA Privacy Notice


 Miscelleanous Forms

Dental & Vision Benefits Termination Notice

Member Information Card

Notice of Privacy Policy

Fund Office Monthly Remittance Reports

Union - Monthly Remittance Report (MS Excel)

Funds - Monthly Remittance Report (Excel)

 Participant's Designation of Beneficiary Forms

(Please note that all Beneficiary forms must be notarized to be considered legal)

Beneficiary Forms Instructions

 Pension Related Forms

Electronic Pension Transfer Authorization

Retiree's Update Verification Letter

Preferred Provider Organization (PPO) Listing

Aetna Inc.

AETNA RX - Prescription Benefits Information 

AETNA Pharmacy Information

Roofers Local #195 
Summary Plan Description Booklets

Health Benefits Summary Plan Description

Summary of Health Benefits and Coverage

Pension Benefits Summary Plan Description

Annuity Benefits Summary Plan Description

Links of Interest:

Roofers Local 195 - Union Website

Aetna Provider Search

Web MD Health

Child Health Plus Insurance

Family Health Plus Insurance

The Uniform Glossary per the Department of Labor

IRS Medical and Dental Expenses Publication 502 (Qualifying Medical Expenses per the IRS)

For any documents that you do not see listed here or for any other Fund Office related information, 
please email us at
or call us at (315) 699-1388 M-F 8:30am to 5:00pm

Roofers Local 195 Fund Office

6200 State Route 31

Cicero, NY 13039

(315) 699-1388 Phone

(315) 699-1390 Fax