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Beneficiary Designee Card Use this form to designate your beneficiary(ies) for your premium free life insurance benefit. CLICK TO DOWNLOAD FILE Dental Enrollment Form Use this form to enroll your dependents or make changes in type of coverage (as allowed by the Plan). CLICK TO DOWNLOAD FILE Dental Reimbursement Claim Form Use this form if you are covered under the traditional fee-for-service dental plan. You may attach your dentist's itemized receipt to the form or have your dentist complete and submit. CLICK TO DOWNLOAD FILE Davis Vision Out-of-Network Claim Form Use this form to request reimbursement for sevices received from providers who do not participate in the Davis Vision network. Follow additional instructions provided on the claim form. CLICK TO DOWNLOAD FILE Dependent Care Reimbursement Request Form 2004-05 Use this claim form to submit eligible dependent care expenses incurred between September 1, 2004 and August 31, 2005. A separate claim form is required for each member of your family. CLICK TO DOWNLOAD FILE Health Care Reimbursement Request Form 2004-05 Use this claim form to submit eligible health care expenses incurred between September 1, 2004 and August 31, 2005. A separate claim form is required for each member of your family. CLICK TO DOWNLOAD FILE One Time Dental Authorization 2004-05 If you have the Health Care FSA for Plan Year 09/01/04 - 08/31/05 and the fee-for-service dental plan, use this form to permit processing any out-of-pocket expenses through your Health Care Account. CLICK TO DOWNLOAD FILE Dependent Care FSA Worksheet Use this worksheet to assist you in estimating your annual dependent care expenses. It may help you to decide if you want to elect to participate in the Dependent Care Flexible Spending Account. CLICK TO DOWNLOAD FILE Dependent Care FSA Enrollment Form Return completed form to JFT Health and Welfare Fund for receipt no later than August 31, 2005. Enrolling as a newly eligible Employee, receipt of form must be before end of your Waiting Period. CLICK TO DOWNLOAD FILE Health Care FSA Worksheet Use this worksheet to assist you in estimating your annual health care expenses. It may help you decide if you want to elect to participate in the Health Care Flexible Spending Account. CLICK TO DOWNLOAD FILE Health Care FSA Enrollment Form Return completed form to JFT Health and Welfare Fund for receipt no later than August 31, 2005. Enrolling as a newly eligible Employee, receipt of form must be before end of your Waiting Period. CLICK TO DOWNLOAD FILE Dependent Care Reimbursement Request Form 2005-06 Use this claim form to submit eligible dependent care expenses incurred between September 1, 2005 and August 31, 2006. A separate claim form is required for each member of your family. CLICK TO DOWNLOAD FILE Health Care Reimbursement Request Form 2005-06 Use this claim form to submit eligible health care expenses incurred between September 1, 2005 and August 31, 2006. A separate claim form is required for each member of your family. CLICK TO DOWNLOAD FILE One Time Dental Authorization 2005-06 If you have the Health Care FSA for Plan Year 09/01/05 - 08/31/06 and the fee-for-service dental plan, use this form to permit processing any out-of-pocket expenses through your Health Care Account. CLICK TO DOWNLOAD FILE DISCLAIMER | HOME