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Forms & Notices





Alternate Coverage Waiver Form 


American Cencer Society Programs & Services (4/5/2010)

Application for Health Plan Retirement


Authorization for the Release of Information
2/16/2010

Base Benefits Only 2/19/09  


Beneficiary Designation Form


Change of Address Form


COBRA Election to Continue Coverage


COBRA Initial Notification of Rights


COBRA Notice of Continuation of Coverage


COBRA Subsidy Opt Out Request for Reimbursement Form


Dependent Student Eligibility Form


Dental News Bulletin 6/18/2007


Disability Application


Disability Claim Form, rev. 10/2005


Disability Continuation Form


Disability Definition


Educational Reimbursement Claim Form


Educational Reimbursement Plan Brochure
 (1/2010)


Eligibility and Self-Payments
(5/29/2009)


Employee Retention Plan Brochure (9/23/09) 

Employee Retention Plan Retro-Payments Explanation (3/9/08)


Enrollment Form - For Union Members Only
 


Health Application for Surviving Spouse

Life Insurance Information:
     - Summary of Benefits
     - Insurance Certificate
     - Insurance Policy Booklet


Medicare Part D


Notice Regarding Class Action-Remeron May 2005


Opt Out Explanation


Opt Out Request for Reimbursement


Other Insurance Accident/Illness Form


Policy for Spouses with Other Health Coverage


Postcard Mailing - Policy Update 12-22-05


Retiree/Early Retiree Health Self-Payment Schedule, effective 1/1/2009
(5/7/2008)


Retirement Checklist - Health
 (4/12/2010)


Rx Claim Form from RESTAT 9-2007


Rx Drug Coverage and Medicare for Non-Paramount Elite Retirees 11-2005


Rx Drug Coverage for Paramount Elite Retirees 11-2005


Rx Drug Coverage for Retirees Plan Comparison - chart 11-2005


Step Therapy Brochure for Proton Pump Inhibitors 1-18-2007


Step Therapy Brochure for Non-sedating Antihistamines 1-18-2007


Step Therapy Explanation 1-18-2007


Step Therapy Physician Review Form 1-18-2007


Summary Annual Report 2007
(financial information)

Summary Annual Report 2006 (financial information)

Summary Annual Report 2005 (financial information)

Summary Annual Report 2004 (financial information)


Summary of Benefits Brochure (legal size - 9/25/2008)


TEWF Plan Changes May 05


Toledo Electrical Welfare Fund Summary Plan Document


Toledo Electrical Welfare Fund Schedule of Benefits

Vision Sevice Plan Benefits Summary (4/7/09) 

Vision Service Plan Claim Form (rev. 1/10)


Your Privacy Rights Under HIPAA

Check out the updated SFBF/VEBA booklet for the newest rates and allowed expenses! (9/10/2008)


VEBA/SFBF Basic Description


2005 Pension/VEBA statement mailing insert

Click here to download VEBA claim form * (11/6/09)
Click here to download the Automatic Reimbursement Election form


Click here to download SFBF New Benefit - Type I & Type II - 01/2005

*To obtain reimbursement for mileage, attach the following information to your VEBA claim form:

  • Date
  • Patient Name
  • Round-trip mileage
  • Name of the doctor, pharmacy or medical facility

Submit this information on a VEBA claim form. Reimbursement for mileage effective January 1, 2010 is 16.5 cents per mile.

Toledo Electrical Benefit Plans
727 Lime City Road
Rossford, OH 43460
(419) 666-4450
©2008 Copyright Toledo Electrical Benefits