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  Retiree Health Services

Serving retirees of Local Funds

                  191   404    443  493  671A  1035                     

609 West Johnson Avenue
2nd floor
Cheshire, CT 06410  


Monday - Friday

      8:30 a.m. - 4:30 p.m.


Phone: 800-292-8340

Fax:      203-250-1232

Please watch your USPS mail for important plan information

                  Please return your 2024 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 Retiree Health services office first when submitting a claim or providing information.

Beige House

Change of address

Hot Air Balloons

Designation of Beneficary

Annual Information Request

Making Notes

Plan SR Application 

Dollar Bill in Jar

Benefit payment via Pension 


Benefit Cancellation


Covid 19 over the counter test kit  Reimbursement

Signing a contract

Death Benefit Application 

Authorization to release PHI 

Directions to Health Services office 

Business Meeting

Summary Annual Report


                             Document & Information Check list


                                                            Complete Annual Information Request form                               


             Address(you or your dependents)                                                     Birth ,Marriage,Death Certificate

             Telephone                                                                                              Beneficiary designation

             Family status (such as marriage)                                                      Divorce Decrees

             Covered by other insurance                                                                Court Ordered Health Coverage


                                                                       Claims payment may require:

                                                                   How, When and Where an injury occurred

                                                                   Information about other Insurance 

                                                                   Information about any action against Third Party 

                                                                   Reimbursement Agreement form


                                                          Claim filing limit is 2 years from date incurred

                                                  Request an appeal within 180 days from the claim denial 

Please contact Retiree Health Services office for questions concerning eligibility,  benefits and claim payment.

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