Forms
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
- Aetna Claim Form (for claims incurred on or after 1/1/2025)
- CVS Caremark Prescription Reimbursement Claim Form (for claims incurred on or after 1/1/2025)
- OptumRx Home Delivery Order Form (for claims incurred on or before 12/31/2024)
- OptumRx Prescription Reimbursement Form (for claims incurred on or before 12/31/2024)
- Anthem Claim Form (PDF) (for claims incurred on or before 12/31/2024)
- 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
Sick Fund Forms
- Sick Fund Application (PDF)
- Sick Fund Withdrawal Form (Retired or Leaving Industry Permanently (PDF)
FAQs
What is our Dental Coverage?
The Fund offers Dental Benefits coverage to all eligible participants and their eligible dependents. Sele-Dent administers all dental and orthodontia claims for the Plan. The Fund has established a Local 94 Network of Participating Providers, as well as the Sele-Dent PPO Network, where eligible participants can receive discounted dental services. For a complete list of providers and for more information about your Dental Benefits, please see the Dental Benefits section of this site.