Vision Plan Forms

This page provides a description of and links to National IAM Benefit Trust Fund forms related to Fund vision plans. Click the form titles in the table below to review or download copies.

Form

Description

Eligible Dependent Certification Form (PDF)

Eligible employees who designate eligible dependents who are not the employees' biological children, or who have a different last name from the employee, must certify the dependent's eligibility for coverage by completing and submitting this form in addition to the Enrollment Form.

Enrollment Form (PDF)

Eligible employees may enroll in a National IAM Benefit Trust Fund vision plan by completing and submitting this form. This form is also used to enroll eligible dependents.

Disabled Dependent Certification Form (PDF)

Eligible employees wishing to designate an eligible disabled dependent must complete and submit this form in addition to the Enrollment Form.

Physician Certification of Disability Form (PDF)

The Physician Certification of Disability Form must be completed by the dependent's attending physician. It should be submitted along with the Enrollment Form and the Disabled Dependent Certification Form.

Vision Claim Form (PDF)Use this form for claims through December 31, 2015.

After receiving vision care services, complete a Vision Claim Form. Submit the completed form to the Benefit Trust Fund along with the itemized receipt from your vision care provider.

Waiver Form (PDF)

Eligible employees wishing to waive coverage must complete and submit this form.

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Remember to include an itemized receipt from your vision care provider when submitting your Vision Claim Form.

Frequently Asked Question (FAQ)

How many different plans does the Fund offer?

The Fund offers multiple Medical, Dental, and Vision plans. Short-Term Disability and Life and Accidental Death & Dismemberment benefits are also available.

How do I notify the Fund of my address change?

If you move, please notify the Fund of your new address. To change your address,
fill out a new Enrollment Form and mail or fax it to the Fund using the mailing address or fax number found on the form. Always complete a new Enrollment Form when you have a change in personal information.

Who processes health care plan claims?

Medical claims are processed by CIGNA Healthcare. Dental claims are processed by Delta Dental Insurance Company, and Vision claims are processed by Fund Office staff.

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