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)

DisabilityAllocationClaimForm

AETNA MAIL Order RX Form

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 195funds@twcny.rr.com
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

195funds@twcny.rr.com