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  • Affidavit Declaring Marital Status

  • Application for Member Death Benefit

  • Authorization for Use and Disclosure of Protected Health Information (PHI)

  • Beneficiary Designation Form

  • Blue Cross Blue Shield Enrollment Form and Dependent Status

  • Change of Address Request

  • Election Form for Health Care Coverage

  • Election to Discontinue Coverage

  • MRA Reimbursement Claim Form

  • Pension Deduction Authorization for Health Self-Payment

  • Retiree Information Form

  • Totally and Permanently Disabled Form


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    Upper Peninsula Plumbers' & Pipefitters' Fringe Benefit Funds
    6525 Centurion Drive
    Lansing, Michigan  48917-9275
    Phone: 517.321.7502 | Toll Free: 800.342.1730 | Fax: 517.321.7508