Documents & Forms Annuity Documents & Forms ANU - Annuity Beneficiary Form 10.2019 ANU - Determination Letter from IRS 021116 ANU - Notice of Military Service Credit (USERRA) ANU - Plan Document effective 013015 and Amendments updated 06292021 ANU - Summary Annual Report 2017 (published 2018) ANU - Summary Annual Report 2018 (published 2019) ANU - Summary Annual Report 2019 (published 2020) ANU - Summary Annual Report 2020 (published 2021) ANU - Summary Plan Description (effective 07012019) and Plan changes thru 12012021 ANU - Trust Agreement and Amendments 07012020 Employers Documents & Forms EC - 10 - Payroll Auditing FAQ (Revised 202002) EC - 14 - Contribution Due Date Notice (Published 201402) EC - 3 - ACH for BNF Holding Account Information 20191113 EC - 4 - Employer Information Request Form (Revised 20181120) EC - 7 - Alumni Agreement Important Information Notice (Published 201709) EC - 8 - Employer Alumni Agreement (Revised 20191114) EC - 9 - Employee Alumni Election Change Form (Revised 20220208) EC - ANU - Summary Annual Report 2017 (published 2018) EC - ANU - Summary Annual Report 2018 (published 2019) EC - ANU - Summary Annual Report 2019 (published 2020) EC - ANU - Summary Annual Report 2020 (published 2021) EC - ANU - Summary Plan Description (effective 07012019) and Plan changes thru 07012020 EC - ANU - Trust Agreement and Amendments 07012020 EC - PEN - 13th Pension Plan Restatement effective 020115 and Amendments 06292021 EC - PEN - 14th Pension Plan Restatement effective 06012022 and Amendments 06142022 EC - PEN - 2018 FASB Disclosures 201911 EC - PEN - 2019 FASB Disclosures 202011 EC - PEN - 2019 Rehabilitation Plan EC - PEN - 2020 FASB Disclosures 202111 EC - PEN - 2020 Funding Improvement Plan EC - PEN - 2021 FASB Disclosures 202211 EC - PEN - 5500 Summary Notice 104(d) 2017 (published November 2018) EC - PEN - 5500 Summary Notice 104(d) 2018 (published November 2019) EC - PEN - 5500 Summary Notice 104(d) 2019 (published November 2020) EC - PEN - 5500 Summary Notice 104(d) 2020 (published November 2021) EC - PEN - 5500 Summary Notice 104(d) 2021 (published November 2022) EC - PEN - Notice of Annual Funding 2018 (published April 2019) EC - PEN - Notice of Annual Funding 2019 (published April 2020) EC - PEN - Notice of Annual Funding 2020 (published April 2021) EC - PEN - Notice of Annual Funding 2021 (published April 2022) EC - PEN - Notice of Plan Status 2018 (published 2019) EC - PEN - Notice of Plan Status 2019 (published 2020) EC - PEN - Notice of Plan Status 2020 (published 2021) EC - PEN - Summary Plan Description effective 6.1.2022 EC - PEN - Summary Plan Description effective 7.1.2016 and Plan changes thru 12.1.2021 EC - PEN - Withdrawal Liability Valuation as of 123120 EC - PEN - Withdrawal Liability Valuation as of 123121 EC - PEN – Trust Agreement effective 1-12-1983 and Amendments 19-40 Health & Welfare Documents & Forms HW - 2018 Evidence of Coverage and SPD and SMM Notices of Plan Amendments HW - 2022 National Preferred Formulary Drug List HW - 2022 United Healthcare Plan Guide HW - Appointment of Authorized Representative Form HW - Authorization Form to Release Personal Information HW - Authorization to Release Protected Health Information HW - BNF Vision Claim Form (202109) HW - COB and Information Verification Form (202110) HW - COBRA AEI Notice of Other Coverage Form HW - COBRA Continuation Coverage Election or Rejection Form HW - COBRA Request for Treatment as AEI Subsidy Form HW - Children's Health Insurance Program 2022 HW - Dependent Child Enrollment Form HW - Designation of Beneficiary Card HW - Disclaimer of Benefits Form HW - Disclosure Notice No Surprise Billing HW - Express Scripts COVID19 TEST Claim Form HW - Express Scripts Prescription Drug Claim Form HW - M Coverage Enrollment Form updated 100121 HW - M Coverage Open Enrollment Packet for 2023 HW - Minimum and Affordability Status 2020 HW - New York Life Long-Term Disability Information HW - Notice of Creditable Prescription Drug Coverage 2022 HW - Privacy Practices 2022 HW - Summary Annual Report 2020 (published 2021) HW - Summary of Benefits and Coverage Active 2023 HW - Summary of Benefits and Coverage Retiree 2023 HW - Summary of Benefits and Coverage Uniform Glossary HW - Trust Agreement 03072022 HW - Womens Health and Cancer Rights Act 2022 Pension Documents & Forms PEN - 13th Pension Plan Restatement effective 020115 and Amendments 06292021 PEN - 14th Pension Plan Restatement effective 06012022 and Amendments 06142022 PEN - 2018 Pension Funding Improvement Plan PEN - 2019 Rehabilitation Plan PEN - 2020 Funding Improvement Plan PEN - 20th SRWR Local Labor Shortage List 09082022 PEN - 5500 Summary Notice 104(d) 2016 (published November 2017) PEN - 5500 Summary Notice 104(d) 2018 (published November 2019) PEN - Application Instructions (revised 10.12.2020) PEN - Application Timeline 2017 PEN - Determination Letter from IRS 110615 PEN - Direct Deposit Letter and Form (1.19.2021) PEN - Notice of Annual Funding 2017 (published April 2018) PEN - Notice of Annual Funding 2018 (published April 2019) PEN - Notice of Annual Funding 2019 (published April 2020) PEN - Notice of Annual Funding 2020 (published April 2021) PEN - Notice of Annual Funding 2021 (published April 2022) PEN - Notice of Plan Status 2017 (published 2018) PEN - Notice of Plan Status 2018 (published 2019) PEN - Notice of Plan Status 2019 (published 2020) PEN - Notice of Plan Status 2020 (published 2021) PEN - Pension Benefit Factor Chart Effective 10-1-2017 for Non grandfathered Status FINAL PEN - Pension Benefit Factor Chart Effective 5.1.2019 for Non grandfathered PEN - Special Retiree Work Rule Request Form PEN - Summary Plan Description effective 6.1.2022 PEN - Summary Plan Description effective 7.1.2016 and Plan changes thru 12.1.2021 PEN - W-4P Tax Form (US only) PEN – Trust Agreement effective 1-12-1983 and Amendments 19-40 Pen - Pension Benefit Factor Chart Effective 100117 for Grandfathered Status Final BNF - Authorization Form to Release Personal Information BNF - Change of Personal Information Form (Aug 2021) BNF - EBSA Online Security Tips