To be eligible for this benefit,you must be currently insured by the Health & Welfare plan of Local Union 373. You,or any member of your immediate family is eligible for reimbursement for optical charges,including examinations,prescription eyeglasses or contact lenses. Dependants shall include your lawful spouse and dependent children up to their 26th birthday. You are eligible for a reimbursement of up to $100.00 every two consecutive calendar years beginning with the odd numbered years for yourself and an additional amount for each eligible dependent. Benefits are not assignable. Payment will only be made to you. This claim form must be completed fully, and a statement or reciept must show: Name of patient;name of provider (Doctor, Optometrist, Optician); the date the charges was incurred and that the charge was paid. Do not submit cash register receipts or cancelled checks. They will be returned. Each charge must be accompanied by a complete form.

Insured's Name ________________________________       SS# ___________________________

Address: _______________________________________________________________________


Patient's Name ___________________________________________________________________

If dependent, relationship to member ___________________________________________________

This is a claim for reimbursement for: (check one)

Examination ____________   Prescription Eyeglasses ____________   Contact Lenses ____________

Providers Name __________________________________________________________________

Providers Address: ________________________________________________________________


Phone Number ________________________ Date Of Service ______________________________

Charges ________________________

I, the undersigned declare that the above claim is for myself, or an eligible dependent member of my family, and authorize the Trustees of the Health & Welfare Plan of Local Union 373 to verify the claim as may be required.

Date ________________________              Signed ______________________________________

___ I will pick my check up at the office                        ___ Please mail my check to me