Downloads: Health and Security Claim Forms Statement of Student Enrollment Enstar Life ADD Beneficiary Form Caremark Mail Service Form Caremark Reimbursement Form 367-262-Shaw Life ADD Beneficiary Form Local 367 Health Info (HIPPA) Large file warning! Files require Adobe Acrobat Reader

UA Local 367 Home Health and Security Effective January 1, 2000 CLAIMS ARE ADMINISTERED BY: Alaska Pipe Trades UA Local 367 c/o Zenith Administrators (formerly known as Administration Services Inc.) PO BOX 5434 Spokane, WA 99205-0434 http://www.ualocal367.org/hwforms_files/ 1(800) 716-0300 Go to www.admin-serv.com for more info. For ELIGIBILITY STATUS, HS CLAIM FORMS , ENROLLMENT FORMS or ID CARDS, please contact: Alaska Pipe Trades U.A. Local 367 Health & Security Trust Note: A completed enrollment form is now required to obtain coverage. David Peterson, Trust Administrator PHONE: (907) 562-2810 extention 2 FAX:     (907) 562-0467 E-Mail: Peterson@ualocal367.org Effective JANUARY 1, 2007 The Retail Prescription Drug Program and The Mail Order Prescription Drug Program are administered by: Caremark (866) 818-6911 Go to www.caremark.com for Claim Forms and other info. RX Group No.: AKPIPE PCN: WISRX BIN #: 004336