Forms

These forms are in Adobe PDF format. If you don't have Adobe Acrobat Reader, you can get the download here.

AFSCME:

Membership Application

AFSCME Local 2076 Health and Welfare Trust Fund:

Life, Disability and Beneficiary Enrollment Form
Termination Form

Landmark Chiropractic:

Enrollment Form

Prudential Disability Claim:

Employee Statement (Page 1)
Employee Statement (Page 2)
Attending Physicians Statement (Page 1)
Attending Physicians Statement (Page 2)

Prudential Life Insurance:

Beneficiary Form

Spectera Vision:

Enrollment Form

United Concordia Dental:

Enrollment/Change Form

AFLAC:

Claim Form

When completed, all forms must be returned to the Trust Administrative office at:

AFSCME Local 2076 Health and Welfare Trust Fund
c/o Design Benefits Administrators
2275 South Main Street
Corona, CA 92882