Teamsters Local 677 Health Services and Insurance Plan
Trustees
John P. Capobianco Paul Ayoub
Michael J. Rinaldi Helga A. Schmidt
1871 Baldwin Street
Waterbury, CT 06706
Hours
Monday - Friday
8:00 a.m. - 5:00 p.m.
Phone: 203-755-2906
Phone: 800-992-2250
Fax: 203-755-3992
Please return your 2020 Annual Information Request form
Please show your ID card to the health care provider
Your id starts with TSJ followed by 7 numbers.
Important information is located on back of card
Fill in forms to print and mail
The below forms are here for your convenience. Please contact your Local Fund office first when submitting a claim or providing information.
Medical Massage Reimbursement
Prescription
Reimbursement
Reimbursement lien agreement
Authorization to release PHI
Affidavits
Marital Status
Financial Responsibility
Summary Plan Description
Residence Spouse as of a date
Residence Spouse
Residence Dependent
Paternity
