UFCW Unions & Participating Employers

NETime Benefit system

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Important Notices

Notice of Privacy Practices
Prescription Drug\Medicare Creditable Coverage
QDRO

Downloads (Forms)

Application for Pension
Change of Address Form (Pension)
Change in Beneficiary Form
Coordination of Benefits Form
Electronic Funds Transfer (“EFT”) Form
HIPAA Authorization Form
LabCorp Facility List
(Plan Y20 Participants Only)

Notice of Continuation or Termination of Disability for Group Accident & Sickness Benefits
Benefit Services Request Form (Pension & Severance)
Pension Plan Highlights
Pension Tax Withholding Form (Federal)
Pension Tax Withholding Form (State)
Scholarship Preliminary Application
Subrogation Agreements
Weekly Accident and Sickness Claim Form

Kroger Richmond Tidewater Downloads

Kroger Roanoke Downloads

Summary Plan Description Booklets

Plan JS SPD
Plan JSS2 SPD
SMMs (Benefit Changes) to Plan JSS2 SPD
Plan Y SPD
SMMs (Benefit Changes) to Plan Y SPD
Plan Y20 SPD
SMMs (Benefit Changes) to Plan Y20 SPD
Plan K2 SPD
SMMs (Benefit Changes) to Plan K2 SPD
Plan K20 SPD
SMMs (Benefit Changes) to Plan K20 SPD
Plan T SPD
SMMs (Benefit Changes) to Plan T SPD
Plan Z SPD
Legal Benefits Fund SPD
Pension Fund SPD
SMMs (Benefit Changes) to Pension Fund SPD
Scholarship Benefit SPD

Summary of Benefits and Coverage

JS SBC
JSS2 SBC
Y SBC
Y20 SBC
Z SBC
Richmond Tidewater Standard SBC
Richmond Tidewater Plus Plan SBC
Richmond Tidewater Premium Plus SBC

For Your Benefit Newsletter

March 2014
June 2014
December 2013
September 2013
June 2013
March 2013
December 2012
September 2012
June 2012
March 2012

Useful Links

CareFirst PPO
GVS – Group Vision Service
Kaiser Permanente
Informed Rx
UFCW Local 400
UFCW Local 27
Value Options

Useful Numbers

InformedRx 800-645-3332

Group Dental Svc 800-242-0450

InforMed 866-290-8147

Value Options 800-454-8329

Group Vision Svc 866-265-4626

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.