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UFCW & EMPLOYERS BENEFIT TRUST
2200 Professional Drive Suite 200, Roseville, California 95661
Telephone (800) 552?2400 ? Facsimile (925) 746?7549
www.ufcwtrust.com
KAISER CO?PAYMENT
REIMBURSEMENT CLAIM FORM
UFCW & Employers Health and Welfare Trust Fund
Applies only to Married Participants who have both elected Kaiser and their eligible dependents
Participant’s Social Security Number: ___ ? ___ ? ___
Spouse’s
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