top of page
Teamsters Local 404 Health Services and Insurance Plan
Trustees
Frank A. Rossi Robert M. Sullivan, Jr.
Bryan Donovan Jr. Larry Keefe
115 Progress Avenue
Springfield, MA 01104
Phone: 413-733-2191
Fax: 413-732-7147
Hours
Monday - Friday
8:30 a.m. - 4:30 p.m.
Please watch your USPS mail for important plan information
Please return your 2022 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
Covid 19 over the counter test kit Reimbursement
Authorization to release PHI
Affidavits
Marital Status
Financial Responbility
Residence Spouse as of a date
Residence Spouse
Residence Dependent
Paternity
Directions to Health Services office
Summary Plan Description
Summary Annual Report
Paper Claims Address:
Teamsters Health Services Local 404
115 Progress Avenue
Springfield, Ma 01104
PAY ID #06085
GROUP # JCT048M003
Please contact Health Services office for questions concerning eligibility, benefits and claim payment.
bottom of page