Food Employers Labor Relations Association (FELRA & UFCW)

NETime Benefit system

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Important Notices

FELRA and UFCW List of ACA Preventive Services
Notice of Privacy Practices
Perscription Drug\Medicare Creditable Coverage
QDRO
Retiree Work Rules

Downloads (Forms)

Accident & Sickness Application
Benefit Service Request Form (Pension & Severance)
Change of Address Form (Pension)
Change in Beneficiary Form
Coordination of Benefits Form
Electronic Funds Transfer (“EFT”) Form
Kaiser HMO Option for Plans I and X
Kaiser HMO Option for Plan XX
HIPAA Authorization Form
LabCorp Facility List
Notice of Continuation or Termination of Disability for Group Accident & Sickness Benefits
FELRA Cvr. Ltr. and Pension Application
MAP Cvr. Ltr. and Pension Application
Pension Tier 1 Highlights
Pension Tier 2 Highlights
Pension Tax Withholding Form (Federal)
Pension Tax Withholding Form (State)
Scholarship Preliminary Application
Severance Application
Severance Beneficiary Registration Card
Severance MD State Tax Withholding Form
Severance Tax Withholding Form (Federal)
Subrogation Agreements

Download Summary of Benefits and Coverage

FELRA Plan I 2014 SBC
FELRA Plan X 2014 SBC
FELRA Plan XX 2014 SBC

FELRA Plan I 2013 SBC
FELRA Plan X 2013 SBC
FELRA Plan XX 2013 SBC

Summary Plan Description Booklets

Plan XX Health & Welfare SPD
SMMs (Benefit Changes) to FELRA Plan XX SPD
Plan X Health & Welfare SPD
SMMs (Benefit Changes) to FELRA Plan X SPD
Plan I SPD
SMMs (Benefit Changes) to FELRA Plan I SPD
Plan I Retiree SPD
SMMs (Benefit Changes) to FELRA Plan I Retiree SPD
FELRA & UFCW Pension Fund SPD
UFCW and FELRA Severance Plan SPD
SMMs (Benefit Changes) to UFCW and FELRA Severance Plan SPD
Legal Benefits SPD
SMMs (Benefit Changes) to UFCW & FELRA Legal Benefits Fund SPD
Scholarship Benefit SPD
CIGNA Retiree Regular Plan Coverage
SMMs (Benefit Changes) to FELRA CIGNA Retirees SPD
CIGNA Retiree Comprehensive Plan Coverage

For Your Benefit Newsletters

December 2013
September 2013
June 2013
March 2013
December 2012
September 2012
June 2012
March 2012

Useful Links

Advantica
CIGNA HealthCare
Care Allies
24 – Hour Nurseline
CareFirst PPO
Group Dental Services of MD
Kaiser Permanente
Medco Health Solutions, Inc
UFCW Local 400
UFCW Local 27
Value Options

Useful Numbers

MEDCO 800-903-8325

Group Dental Svc 800-242-0450

SHPS 866-511-1462

Advantica 866-425-2323

CIGNA 800-244-6224

Value Options 800-353-3572

Health Dialog 866-469-6331

These forms are published on this page by Associated Administrators, LLC
on behalf of the Client Fund and are meant solely for the use of their participants.