Forms

Find and download different forms relating to Local 94 and its affiliated Benefit Funds.

Local 94 Forms

• Contact Information Form (PDF)
• Dues Checkoff Form (PDF)
• PAC Checkoff Form (PDF)

Annuity Fund Forms

• For all Annuity Fund Forms, such as a distribution request, loan application or beneficiary form, please visit the mylife.jhrps.com. website.

Health and Benefit Trust Fund Forms

• OptumRx Home Delivery Order Form
• OptumRx Prescription Reimbursement Form
• Empire Claim Form (PDF)
• Sele-Dent Claim Form (PDF)
• Coordination of Benefits Form (PDF)
• Beneficiary Designation Form (PDF)
• Commercial Loss of Time Claim Form (PDF)
• School Loss of Time Claim Form (PDF)
• Authorization to Release PHI Form (PDF)
• Commercial In-House Claim Form (PDF)
• School Retiree Medicare Related Premium Reimbursement Form
• School In-House Claim Form (PDF)

Pension Forms

• For all Pension forms, such as beneficiary, direct deposit, and retirement application forms please visit the Central Pension Fund website.

Scholarship Fund Form

• Scholarship Fund Application (PDF)
• Journal Ad Contract (PDF)

Sick Fund Forms

• Sick Fund Application (PDF)