UFCW Local 135
First Name*
Last Name*
Phone*
Email
Leave blank if no changes
Street address
City
State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming—District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Last 4 digits of Social Security number or Employer ID*
Questions or comments
Δ
Withdrawal or Return to Work
WithdrawalReturn to Work
Reason for Withdrawal
For TerminationFor Leave of Absence
(Must be out at least one full calendar month for LOA)
Withdrawal Date
Return to Work Date
Company name and location
Phone
Additional Information
Important: To enroll in healthcare, you must call our insurance office at (619)298-7772 ext. 8. The forms below are for currently enrolled members.
Street address*
City*
State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming—District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Company name and location*
What form(s) are you requesting?* Check all that apply.Vision formDental formOrthodontic formAddress form
Email*
Message
What type of volunteering are you interested in?* Check all that apply.PicketingPhone BankingWalking PrecinctsFood DistributionEvent SupportOther