Application to have your SASMI premiums paid directly to your Local Union Health Plan from your HCRA Account

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

SASMI will pay your health care premiums based on the information you provide below.

This payment(s) will continue until you formally submit a request to cease payments.

Funds will be deducted from your HCRA account as directed and sent directly to your health care provider.

***Currently we only make direct payment to Local Union Health Funds that have signed a Business Associates Agreement.

NOTE: Locals 010, 036, 055, 066, 103, 268, and 293 DO NOT participate in this program.

For any questions, please email us at: OFFICE@SASMI.ORG

Email *

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms