Forms Directory

To view a form, click the form name. Each form can be printed. Completed forms should be mailed to the Fund Administration Office address shown on the form.

To enroll in the Plan, change your personal information or add or change dependents:
Enrollment/Change Form

To designate or change your Death Benefit beneficiary:
Beneficiary Designation Form

To provide the Fund with information about your Spouse's employer's insurance benefits:
Spouse Insurance Coverage Information

To enroll step-children: Dependent Eligibility Affidavit

To authorize HIPAA information to be released to your Local Union or Employer:
HIPAA Authorization Form

To designate or change your Authorized Personal Representative
Personal Representative Designation Form

To change your address: Change of Address Form

To apply for the short term disability benefit: Loss of Time Benefit

To file a MEDICAL claim:
Statement of Medical Claim
please review the Schedule of Benefits for your plan network for further instruction on submission of medical claims

To file a DENTAL claim:
Dental Service Report
please review the Summaiy Plan Description for further instruction on submission of dental claims

To order medication using the SavRX mail-order program:
SavRX Mail Order Prescription Form

to file a VISION claim:
Vision Care Claim Form

to provide the Fund with information about an accident:
Accident Form

to provide the Fund with information about Coordination of Benefits:
COB Analyst Letter - All Groups Form

Download Adobe Acrobat Reader FREE

North Central Illinois Laborers' Health & Welfare Fund
4208 W. Partridge Way Unit 3
Peoria, IL 61615
Telephone: 309.692-0860
Toll Free: 866.692-0860
Facsimile: 309.692-0862
email: ncil@ncil.us