Refund Request "*" indicates required fields Name* First Last Email* What Union are you a part of?*What is your Division/Local/Lodge Number?*Type of coverage you cancelled?*Date you became ineligible for coverage?* Month Day Year Explanation of the reason for the request*Please upload documentation of when you became ineligible (ie: proof of retirement, resignation, suspension). At least one document is required.File #1*Max. file size: 32 MB.File #2Max. file size: 32 MB.File #3Max. file size: 32 MB.This field is hidden when viewing the formPlease upload documentation of when you became ineligible (ie: proof of retirement, resignation, suspension) Drop files here or Select files Max. file size: 32 MB. About Us ServicesClaimsTestimonialsContact Us Services Benefits ManagementEnrollment ServicesBrokerage & Consulting ServicesTPA Services Claims File a ClaimCheck the Status of a ClaimClaim FAQsClaims Progress Update SurveyPost-Claim Feedback Survey
