LOCAL UNION 373 HEALTH & WELFARE FUND
HEALTH REIMBURSEMENT ARRANGEMENT PROGRAM (HRA FUND)
P.O. Box 58 Mountainville, NY 10953 Telephone (845) 534-9765

Name _______________________________ SS# _____________________ L.U. # ________

Address _____________________________________________________________________
                street                          city                          state                           zip

   ECONOMIC ASSISTANCE --------------- Amount Requested $ ____________________

Reimbursable Economic Assistance Benefits:       1.   Out of pocket medical:                       a.     Doctor Bills                       b.     Hospital Bills                       c.     Prescription Drug Co-Pay                       d.     Dental                       e.     Optical       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 ONLY ORIGINAL PAID BILLS WILL BE ACCEPTED FOR REIMBURSEMENT 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 ______________________________________    I will pick my check up at the office                           Please mail my check to me TRUSTEE APPROVAL: ______________________________________      ______________________________________