Painters and Allied Trades District Council 82

HEALTH & WELFARE FORMS

Welfare Forms:

Family Update Form
If you have a life-changing event and need to update dependent information, this form must be completed and sent to the Fund Office, with the appropriate documentation (birth certificate, marriage certificate, divorce decree, etc.).
Change of Address Form
Complete this form to change or correct your mailing address, and return it to the Fund Office.
Change of Name Form
Complete this form to change or correct your name, and return it to the Fund Office.
Authorization for Release of PHI Form
If you want the Plan to disclose your protected health information to another individual(s), persons, class of persons, or organization of your choice (for example, your spouse), you must fill out this form and return it to the Fund Office. If your spouse and/or Dependent child(ren) over the age of 17 (i.e. Dependent child(ren) who are at least 18 years old) want the Plan to disclose their protected health information to you, they also must fill out this form and return it to the Fund office.
Beneficiary Designation Form
To designate a beneficiary for your death benefit, you must fill out this form and return it to the Fund Office.
Dependent Affidavit Form
If you are not married to your natural child’s mother/father, then you need to complete this form, have it notarized, and submit it to the Fund Office with any supporting documents.
Initial Report of Claims Form
If your provider does not automatically submit your bill to the Fund office, Wilson-McShane Corporation, please complete this form and return it to the Fund Office with the appropriate itemized bills.
Subrogation Agreement Form
Complete this form to acknowledge the Fund’s subrogation and reimbursement interests. For more information, please contact the Fund Office.
Initial Disability Form
If you become disabled and are unable to work, you and your physician must complete this form and submit it to the Fund Office, in order to receive the weekly disability benefits.
Supplementary Disability Form
Once approved for the weekly disability benefit, to continue to receive the weekly disability benefit, you will be responsible to complete the Supplementary Disability Form.
Direct Payment ACH Authorization Form
If you are in the Retiree Plan and would like to have your monthly premium deducted from a dedicated account, complete this form.
Inter-Plan Reciprocal Authorization Form
This agreement allows you to transfer your hours back to your original plan if you have worked within another plan (i.e. You are covered under Plan A, but perform work in Plan C).
Reciprocity Request Form
This form is used to transfer hours back to your home fund(s).
Retiree Spousal Waiver of Coverage Form
If you retire and your spouse has other coverage, you must sign this waiver and notarize. You must have written notice and Board approval to return.
Vision Reimbursement Claim Form
Complete this form and mail it to the Fund Office to submit a Vision Claim for Reimbursement.

Forms:

Authorization for Release of PHI Form Link

Supplementary Disability Claim Form Link

Direct Payment ACH Authorization Form Link

Inter-Plan Reciprocal Authorization Form Link

Retiree Spousal Waiver of Coverage Form Link