Forms

These printable forms are in PDF format. You need the Adobe Acrobat Reader to read and print them. If you do not have Adobe Acrobat Reader installed in your system, you need to install it by clicking on the download icon.

 

Annual Claim Form (English), (Spanish) - Complete this form once a year. All fields must be completed and the form must be signed by the member and spouse (if applicable). The completed and signed claim form must be submitted to the Fund Office by July 31st. Failure to submit a completed and signed claim form by July 31st may result in a delay of benefit payments for claims submitted on or after August 1st.

Dependent Over Age 19 Annual Claim Form - Complete this form once a year for dependents age 19 - 25. All fields must be completed and the form must be signed by the dependent and spouse, if married. The completed and signed claim form must be submitted to the Fund Office by May 31st. Failure to submit a completed and signed claim form by May 31st may result in a delay of benefit payments.

Custodial Annual Claim Form - This form is used to provide information for dependent children of divorced parents who do not live with the Laborers' member, but with the other (non-Laborer) parent.  The form requests the name and address of the children's custodial parent and if that parent insures the dependent children through his/her employer.  This form must be completed once a year for children of divorced parents.

Change of Address - Complete this form when you move and want all correspondence and Explanation of Benefits sent to a new address.  The form must list the member's date of birth, old address and phone number, and new address and phone number.  The form must be signed by the member.

Dependent Accident Claim Form - Complete this form when one of your dependents, spouse or child, is involved in an accident or the diagnosis for the treatment being received indicates an accidental injury; i.e., strain or sprain, etc.  For accidents involving your spouse, the form must be signed by the spouse.  For accidents 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).

Dependent Child Over Age 18 Personal Representative Form - Complete this form to designate your parent or another person as a Personal Representative to obtain personal information on your behalf from both the Laborers' Pension and Welfare Funds. Once completed and returned to the Fund, your personal representative will be recorded and they will be able to obtain pension and claim information from the Funds. Please note that your personal representative will need your social security number or alternate identification number and your date of birth when calling for information.

Enrollment Packet - Enrollment Forms for the Retiree Medical Plans 1 -4 – When you are eligible for the Retiree Medical Plan, complete these forms to enroll for coverage. These forms must be completed and submitted at the time you retiree even if you are still eligible for the Active Plan due to your bank of hours. Please contact the Fund Office to verify your eligibility for the Retiree Medical Plan.

HRA Reimbursement - Complete this form when you have out-of-pocket expenses that are not reimbursed by the Plan or eligible premium payments and are requesting reimbursement for those expenses from the Health Reimbursement Arrangement (HRA) Program.  The HRA Program is not available to all members.  Please refer to the HRA Section under Health & Welfare > Benefit Summary for more information on who is eligible for this program. 

Participant Accident and/or Loss of Time (LOT) Claim Form (English), (Spanish) - Complete this form when you are involved in an accident, the diagnosis for treatment indicates an accidental injury; i.e., strain or sprain, etc., or you are disabled and unable to work due to a medical condition and want to receive Loss of Time Benefits.  For an accident, complete and sign the first page (Section 1) only.  To claim Loss of Time benefits, complete the first page (Section 1) and Section 3 on the second page and have your physician complete Section 2 on the second page. 

Personal Representative Form - Complete this form to designate a Personal Representative to obtain personal information on your behalf from both the Laborers' Pension and Welfare Funds. Once completed and returned to the Fund, your personal representative will be recorded and they will be able to obtain pension and claim information from the Funds. Please note that your personal representative will need your social security number or alternate identification number and your date of birth when calling for information.

Prescription Drug Claim Form – Complete 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 her employer.

Vision Form - is no longer needed after January 1, 2012.