Teamsters Local 404 Health Services and Insurance Plan

 Trustees

Frank A. Rossi                   Robert M. Sullivan, Jr.

Victor Santiago                  

       

115 Progress Avenue

Springfield, MA 01104

Fund Manager

Eileen Polizzi

 Phone: 413-733-2191 

Phone: 800-851-3002

Fax:      413-746-9094

 Hours

Monday - Friday

      8:30 a.m. - 4:30 p.m.

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

Authorization to release PHI 

Affidavits

Marital Status

Financial Responbility

Summary Plan Description

Directions to Health Services office 

Business Meeting

Summary Annual Report

Residence Spouse as of a date

Residence Spouse 

Residence Dependent

Paternity

Please contact  Local 404 Health Services office for questions concerning eligibility,  benefits and claim payment.

Please review the Summary Plan Description for further information regarding your plan of benefits.