Refund Request

"*" indicates required fields

Name*

Email*

What Union are you a part of?*

What is your Division/Local/Lodge Number?*

Type of coverage you cancelled?*

Date you became ineligible for coverage?*

Explanation of the reason for the request*

Please upload documentation of when you became ineligible (ie: proof of retirement, resignation, suspension). At least one document is required.

File #1*

Max. file size: 32 MB.

File #2

Max. file size: 32 MB.

File #3

Max. file size: 32 MB.

Hidden

Please upload documentation of when you became ineligible (ie: proof of retirement, resignation, suspension)

Drop files here or

Max. file size: 32 MB.

Questions?

Contact the SMART-TD VLTD Customer Service Center

(224) 770-5328

(224) 770-5328