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Health and Welfare Plan / Forms

Accident-Injury Questionnaire

Complete this questionnaire if you and/or your dependent have been involved in an accident where an injury required medical attention.

Accident-Injury Questionnaire
Address Change Form
Beneficiary Designation Form

Complete this form to designate a person (or persons) to receive benefits that may be payable upon your death. Important: If beneficiaries are not designated as either primary or secondary, all beneficiaries are considered to be primary by default.

Beneficiary Designation Form
COVID19 Disability Application
Enrollment Form

Complete this form to provide information about you and your eligible dependents.This form must be completed and submitted any time family information changes. New members will also need to complete a Beneficiary Form and HIPAA Form.

Enrollment Form
Express Scripts Direct Claim Form

Complete this form to submit prescriptions to Express Scripts for reimbursement when a non-network pharmacy is used or to coordinate benefits when another prescription plan has already paid their portion of the prescription bill.

Express Scripts Direct Claim Form
Express Scripts Home Delivery Form

Complete this form to submit prescriptions to Express Scripts Home Delivery.

Express Scripts Home Delivery Form
Express Scripts Online and Mobile App Registration Instructions
HIPAA Form

Complete this form to authorize the St. Louis Benefit Plans Office to release PHI/ePHI to the individual or entity listed on the form.

HIPAA Form
HIPAA Revocation Form

Complete this form to revoke or terminate permission to disclose PHI/ePHI to a previously authorized person or entity.

HIPAA Revocation Form
Medical Claim Form

Carpenters' Medical Claim form for member/patient claim reimbursement

Medical Claim Form
MetLife Funeral Planning Guide
MetLife Grief Counseling
MetLife Retirewise Brochure
MetLife Retirewise Slipsheet
MetLife Special Needs Planning
Military Leave Activation Discharge Form

Print and complete this form if you have been called to or are returning from active military duty. This form allows you to freeze your health and welfare coverage while you are away and reinstate your coverage upon your return.

Military Leave Activation Discharge Form
Other Insurance Questionnaire
Spousal Coverage Program Brochure
Spousal Coverage Verification Form

Complete this form to provide the Plan with insurance coverage information for both a working and non-working spouse in order to be eligible for Carpenters' coverage.

Spousal Coverage Verification Form
VSP ProTec Rx Safety Glasses Providers eff Jan 1 2016
VSP Reimbursement Form

Complete this form to submit a request for out-of-network claim reimbursement to VSP for eye care charges incurred at a non-VSP provider.

VSP Reimbursement Form
Weekly Disability Form

Both the Member and Physician must complete this form in order for the member to be considered for weekly benefits due to a non work-related accident/illness.

Weekly Disability Form