Forms
Health Plan
Acknowledgement of Summary Plan Description Provisions/SubrogationAddress Change Form
Authorization Form – Protected Health Information
Cancellation of Authorization – Protected Health Information
Enrollment Form
Extended Benefit Recurring Credit Card Payment
Extended Benefits Form – Worker’s Compensation
Medicare D-IRMAA Reimbursement Form
Reimbursement Agreement Form – Worker’s Compensation
Special 14 Day Weekly Income Benefit COVID-19 Quarantine Application Form
Stepchild Affidavit
Weekly Income Benefit Continuation Form
Weekly Income Claim Form – HI Employer Only
Weekly Income Claim Form – NJ Employer Only
Weekly Income Claim Form – NY Employer Only
Weekly Income Claim Form (Except NY, NJ, HI Employers)
Your Rights and Protections Against Surprise Medical Bills
Pension Plan
Address Change FormBenefit Option Outline
Designation of Beneficiary – Pre-Retirement Death-In-Service Benefit
Enrollment Form for Direct Deposit of Pension Payments
Local 1 Elevator Consultant Program Enrollment Request Form and Agreement
Pension Application
Pension Instructions
Pension Release Authorization Form
QDRO Procedures
Retiree Authorization form for Direct Payment to NECPAC
Retiree Beneficiary Change Form
Withholding Certificate for Pension or Annuity Payments W-4P
Annuity Plan
Address Change FormBeneficiary Form
Contribution Form – 401(k)/Roth Contribution/Enrollment/Deferral Change Form
Emergency Coronavirus-related (Phase 2 period) Distribution Application
Rollover Form
