Forms (English Version)
You can download the forms, fill them out on your computer, and then save or print them. After that, you can use the message center in your Member Self-Service Portal to send them to us. If you have any questions about these forms, please call us at (708) 562-0200.
Participant Contact Information
- Change of Contact Information Form - Use this form to update your contact information with the Plan. You can also update your information by logging in to your Member Self-Service Portal.
New Participants
- Enrollment Form - Use this form to enroll or update you and your dependent(s) as well as update beneficiaries.
Verification Claim Forms
- Biennial Claim Form for Members - Use this form every two years to verify your current information, marital status, dependent children, and any other health coverage. You can also complete this form in your Member Self-Service Portal. After signing in you can find this form on the Biennial Claim Form tab. The due date is September 30th.
- Biennial Claim Form for Natural Parents - Use this form to verify whether the other Natural Parent carries health insurance coverage for the dependent children of a divorced or never-married member. Ensure that the other Natural Parent, not the Member, completes this form. Remember that this form must be updated every two years and is due on September 30th.
- Biennial Claim Form for Overage Dependents - Use this form to verify your dependent’s information, marital status, and health coverage when they are between 19 and 26 years of age. If you are a dependent of an “Active” working participant, you must complete this form every two years. If you are a dependent of a “Retiree” participant, you must complete this form annually.
Claim Related Forms
- HRA Reimbursement - Use this form to request Health Reimbursement Arrangement (HRA) reimbursement for your out-of-pocket medical expenses, and premium payments. When submitting this form, please include the required documentation. If you are eligible under the Active Plan 1, you must submit your prescription receipts through the Medical Plan before submitting them through the HRA. To check your HRA balance, sign in to the Member Self-Service Portal.
- Accident Claim / Loss of Time - Active Participant - Use this form if your medical claims provide a diagnosis that could indicate an injury due to an accident, such as a sprain, strain, or laceration. Also, use this form if you are an Active Participant who is disabled and unable to work due to a medical condition and want to receive Loss of Time Benefits. For an accident/injury, fill out and sign Section 1 only. To claim Loss of Time benefits, complete Sections 1 and 3, and ensure that your physician completes Section 2.
- Accident Claim - Retired Participant - Use this form if you are a retiree and your medical claims provide a diagnosis that could indicate an injury due to an accident, such as a sprain, strain, or laceration.
- Accident Claim - Dependent - Use this form if your medical claims provide a diagnosis that could indicate an injury due to an accident, such as a sprain, strain, or laceration. For accidents/injuries involving your spouse, the form must be signed by the spouse. For accidents/injuries involving your children, the form must be signed by the member for minor children (under the age of 18), or by the child (over the age of 18).
- Out Of Network Prescription Drug Claim - Use this form when you need to submit claims for out-of-network prescription drug purchases and/or for payment when the Fund pays second on your prescription drugs, i.e., your spouse has coverage for prescription drugs through his/her employer.
HIPAA / Protected Health Information
- Appointment of Personal Representative - Members, spouses and dependents can use this form to give us permission to disclose your pension (if applicable) and claim information to a specific person(s) designated in the form.
Retiree Enrollment
- Retiree Medical Plan Enrollment Packet - Use this form for enrollment in Retiree Medical Plans 1-4 – When you are eligible for the Retiree Medical Plan. These forms must be completed and submitted at the time you retire even if you are still eligible for the Active Plan due to your bank of hours. Please contact the Welfare Fund Office to verify your eligibility for the Retiree Medical Plan (LIUNA Members included).
Application
- Rollover Election - Use this form to change your choice of payment for the partial lump sum payment, prior to the receipt of your 6th pension check. Partial lump sum payments can be paid directly to the pensioner, minus automatic 20% federal withholding taxes, or rolled over into an IRA account. The payment can also be split up, with a portion of the payment rolled over into an IRA account and the remainder paid directly to the pensioner, minus automatic 20% federal withholding taxes. A Rollover Notice is attached to this form. Only complete this form if you are eligible for the benefit and approved by the Fund Office to complete.
Beneficiary Forms
- Retiree Welfare Beneficiary Designation (Death Benefit) - Use this form to change your beneficiary for death benefits from the Laborers' Welfare Fund, if eligible. Please contact the Fund Office to verify your eligibility.
- Pension Beneficiary Designation (Primary / Contingent) - Use this form to change your Primary and Contingent Beneficiary for your pension benefit. Please note that this form is designed for members who did not elect the Joint and Survivor Annuity option.
- Pension Beneficiary Designation (60 Month Post-Retirement) - Use this form to change your 60 month Post Primary Beneficiary for your pension benefit. You must also complete our Contingent Beneficiary Form if you want to change both Primary and Contingent. Please note that this form is designed for members who elected the 60 month Post Annuity Option.
- Pension Beneficiary Designation (Contingent) - Use this form to change your Contingent Beneficiary for your pension benefit. Please note that this form is designed for members who did elect the Joint and Survivor Annuity option or 60 month Post Annuity option.
Power of Attorney
- Power of Attorney - Use this form to designate a Power of Attorney to handle your financial affairs and authorize someone else to endorse pension checks and complete other Fund forms on your behalf. Please call the Fund for assistance in completing this form.
Disqualifying Employment
- Disqualifying Employment Determination - Use this form to obtain a determination about whether a potential job would be considered Disqualifying Employment. There are two questionnaires included, one must be completed by you and another by your potential employer. Whenever possible, you or the employer should attach a detailed job description.
Annual Verification Statement
- Annual Statement - This form must be completed by all pension recipients between January 1st and May 15th of each year. Failure to return this form and respond to reminder notices sent in April and May will result in a hold on your June pension check or direct deposit. This version requires a notary to certify your signature.
- Annual Statement with Witnesses - This form must be completed by all pension recipients between January 1st and May 15th of each year. Failure to return this form and respond to reminder notices sent in April and May will result in a hold on your June pension check or direct deposit. This version of the Annual Statement form can be completed by any pension recipient who is physically unable to appear before a Notary Public. This version requires that two witnesses certify your signature. These two witnesses cannot be your relatives and must list their contact information on the form.
Tax Withholding Forms
- Citizenship - Use this form if you move out of the United States. There are special federal income tax withholding requirements for non-residents that the Fund Office will determine after you declare your citizenship.
- IRS Form W-4P Withholding Certificate - Use this form to change the federal income tax withholding on your pension payments. If you submit a change on or before the 15th of the month, it will be reflected on your next pension payment. If you submit a change after the 15th of the month, it will be reflected in the month following the next month [for example, if you submit change on March 16, then not reflected until the May 1st pension payment].
- IRS Form W-8BEN Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding - Use this form to waive the automatic federal income tax withholding on pension payments to "Non-Resident Aliens" or non-US citizens, collecting pension while residing in another country, as allowed under the income tax treaty between the United States and that country. Please note that residents of some countries will not be allowed to waive the federal income tax withholding. Please contact the Fund Office to verify your eligibility. See IRS Form W-8BEN Instructions.
Pension Checks
- Request For Stop Payment - Use this form to stop payment on a missing pension check and request replacement on any check that you have not received by the 7th of the month. You should still call the Fund Office to report your check as missing, as it may have been returned to the Fund due to an unreported address change or held by the Fund to obtain the required Annual Statement.