Member Resources/Forms

Additional Member Benefits Information

Benefit Fund Enrollment

• New/Change Member Enrollment Form

EmpiRX – Prescription Coverage

• Welcome to Your EmpiRx Health Prescription Benefit – FAQ
• EmpiRx Health Member Portal

Independence Blue Cross (IBX) – Medical Coverage

• IBX Find a Doctor
• IBX Discounts Flyer
• IBX Get Connected

Delta Dental Coverage

• Delta Dental Benefit Plan Highlights
• Delta Care FAQ
• Delta Dental PPO Overview
• Delta Dental App – Stays Connected

Vision Coverage

• Vision Benefits Flyer

Short Term Disability

• Short Term Disability Benefit Plan
• How to file for Short Term Disability

Pension

• Pension Estimate Request
• Electronic Direct Deposit
• Change Of Information
• Nursing Home Pension Benefit Application form

Retiree

• The Retiree First Announcement Letter
• Frequently Asked Questions
• Retiree First Authorized Representative Form
• Humana Enrollment form

Additional Adobe Fillable Forms

• Beneficiary Form for Death Benefit
• Medicare Reimbursement Form
• Disability IRS Form W4-S 2021