Interstate Brands

www.interstatebakeriescorp.com

Health and Welfare

Health and Welfare Forms

Additional Information

Dental Fee Schedule

Change of Address Form

COBRA

Health and Welfare Plan Schedule

Change of Beneficiary Form

Creditable Coverage

Retiree Dental Schedule (ZR)

COB Yearly Update (Participant)

Disqualifying Employment Rules

Retiree Plan Schedule (ZR)

COB Yearly Update (Qualifying Child)

Request new/additional insurance cards

Dependent Form

Retiree Health Coverage Eligibility Rules

Dependent Eligibility Certification Form

Retiree Health Coverage Premium

Dependent SSN Request Form

Disability Claim Form

Disability Continuance Form

Enrollment Form

Injury Report

Insurance Verification Form

Marital/Divorce Status Form

Pre-existing Condition Form

Qualifying Child Enrollment Form

Rx Solutions Mail Order Form

Rx Solutions Reimbursement Form

Retiree Insurance Verification Form

Student Verification Form