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Forms
Click to view and print any form.
Note: You will need Adobe Acrobat Reader to view and print these forms. If you don't have it, click here to download and install it on your computer.- Enrollment Form*
*This form may be used by all participants, including retirees. - Medical Option Form
- Dental Option Form
- Change of Address Form
- Medical Claim Form
- Proof of Disability Claim Form
- Weekly Benefit - Disability Claim Form
The following form may be used to order material from the Plan Administration Office (HMO Packets, Benefit Packets, Claim Forms, etc.) Or call (510) 796-4676 or (800) 533-0119.