Find and download different forms relating to Local 94 and its affiliated Benefit Funds.
Local 94 Forms
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)
- For all Pension forms, such as beneficiary, direct deposit, and retirement application forms please visit the Central Pension Fund website.
Scholarship Fund Form
Sick Fund Forms
Need to Find a Doctor, Dentist or Vision Specialist?
My adult dependent child is receiving health insurance through an employer. Who is the primary health insurance carrier?
If your dependent child has other group health insurance coverage through an employer, the Plan will generally consider that coverage to be primary and the Plan’s coverage for such child will be secondary in accordance with the Coordination of Benefit (“COB”) rules which is found in the SPD.