Reimbursable Economic Assistance Benefits:
1. Out of pocket medical:
a. Doctor Bills
b. Hospital Bills
c. Prescription Drug Co-Pay
1. Health Insurance Premiums:
a. Retiree Health Insurance Co-Pay
b. Medicare Part "B"
c. C.O.B.R.A. Insurance Premiums
d. Supplemental Health Insurance Premiums
I, the undersigned applicant,declare and represent to the Trustees of the L.U. 373 U.A. Health & Welfare Fund,that all the information set forth herein by me for this application is true and correct and is made for the express purpose as stated and furthermore,give permision the the Trustees to verify submitals as required.
Date ________________________ Signed ______________________________________