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Mail to HRSA-ILA-STD BENEFITS c/o Alicare Inc. P. O. Box 5453 White Plains NY 10602-5453 Customer Service 1-866-975-4090 Fax 1-914-367-4114 HRSA-ILA WELFARE FUND STD CLAIM FORM SECTION 1 TO BE COMPLETED BY MEMBER/EMPLOYEE PLEASE PRINT MEMBER S SOC. SEC. NO. OR I. D. NO. FULL NAME OF MEMBER FIRST MIDDLE LAST DATE OF BIRTH SEX JOB TITLE M F ADDRESS TELEPHONE NO. GANG NO. 1a* HAVE YOU RECEIVED STD BENEFITS DURING THE LAST 12 MONTHS YES NO 2a* LAST DATE OF WORK FOR CURRENT STD PERIOD 3a* HAVE...

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