• 2022 Benefit Fund SPD
• Adding a Child to the Plan Form A copy of the birth certificate and social security card must accompany form.
• Adding a Spouse to the Plan Form A copy of the marriage license and a copy of the social security card for your new spouse must accompany the form.
• Applying for Weekly Disability Packet
• ACH Authorization Insurance Payment
• Claim Form
• Coordination of Benefits Form
• Designating Your Beneficiary Form
• Enrollment Form, Insurance Benefits If applicable, copy of marriage license and/or child(ren) birth certificate(s) must accompany form.
• HIPAA Authorization Form
• HRA Claim Form
• HRA Filing Instructions
• Health Privacy Policy
• SavRx Reimbursement Form
• Statement of Claim Form
• Subrogation Form
• Summary of Benefits - Active & Disabled Employees
• Summary of Benefits - Medicare
• Summary of Benefits - Surviving spouse program
• Vision Claim Form
• Women's Health

• Empower Loan Application
• Hardship Withdrawal Request
• Medical Info Release Form
• Normal Retirement - Termination or Separation of Service
• Retirement Beneficary Form
• Retirement Disability Form
• Retirement Fund SPD
• Reitrement Survivor Application
• Sample QDRO

• Delta Dental & VSP - Complete Enrollment Packet
• Delta Dental & VSP – Summary of Benefits
• Delta Dental & VSP – How to Find a Provider
• Delta Dental & VSP - Cover Letter
• Delta Dental & VSP - Enrollment Form
• Delta Dental & VSP – Monthly & Annual Premium

Enroll in Delta Dental and VSP – Over the phone by calling Nelson Insurance at 502-736-7000

or

Online by visiting ky.deltadental.com/IBEW

or

Complete a paper application and return to:

Delta Dental of Kentucky, Inc.
ATTN: IPU
PO Box 242810
Louisville, KY 40224