Welfare Fund Forms

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Welfare Fund

Welfare Fund Forms

Welcome to the Plumbers Local Union No. 1 Welfare Fund Forms page.

Forms

HRA Claim Form

Please note that HRA benefits are paid by the Fund on a monthly basis. To ensure timely payment of each claim submission completed claim forms must be submitted to the Fund Office no later than the second Tuesday of each calendar month.

Change of Address Form

Beneficiary Designation Form

Dependent Certification Form NEW Adult Child to Age 26

Special Enrollment Form NEW Adult Child to Age 26

Benefit Enrollment Form

Universal Enrollment Form

PHI Authorization Form

PHI Cancellation Form

Certification of Medical Necessity Form

Qualified Relative Certification Form

Dental Claim Form Out-of-Network

Vision Claim Form Out-of-Network

Medicare Claim Form

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Fund Office News

	ASB Fund 2013 Benefit Payment Information Wed, Jan 2, 2013 For 2013 Benefits will continue to be paid by the Fund on a monthly basis, application for Benefit Forms are due in the Fund Office no later than the Fourth Tuesday of each calendar month for the subsequent month's Benefit payment. See attached letter for additional information. Click Here to download the document for the ASB Fund Benefit Payment Schedule.

	Q&A About 401(k) Plan Casualty Losses and Hardship Distributions Fri, Nov 16, 2012 The attached Q&A is an explanation of the hardship withdrawal benefit that may be available to you to repair your home in the wake of Super-Storm Sandy.

	Q&A About ASB Fund Emergency Benefits For Disaster, Fire or Flood Fri, Nov 16, 2012 The attached Q&A is an explanation of this emergency benefit that may be available to you to help you meet the needs arising from this catastrophic weather emergency.

	13th Annual Employee Benefit Fair - SAVE THE DATE! Wed, Oct 3, 2012 When: Wednesday, October 17th from 3:00 p.m. to 6:30 p.m. Where: Plumbers Local Union No.1 Training Facility 37-11 47th Avenue, Long Island City. Click Here to view document.

	ASB Fund 2012 Benefit Payment Information Thu, Jan 5, 2012 For 2012 Benefits will continue to be paid by the Fund on a monthly basis, application for Benefit Forms are due in the Fund Office no later than the Fourth Tuesday of each calendar month for the subsequent month's Benefit payment. See attached letter for additional information. Click Here to download the document for the ASB Fund 2012 Benefit Payment Schedule.

	New Economic Downturn Distribution Wed, Apr 6, 2011 As part of a continuing effort to aid members during the continued downturn of the economy, the Trustees of the Plumbers Local Union No. 1 401(K) Savings Plan have added a new, temporary, distribution option from the Plan. As a brief overview, the Plan is comprised of two types of contributions, 401(k) Elective Deferrals and Employer Contributions. This new distribution option allows participants to withdrawal a portion of your Employer Contribution Account. The details of the Economic Downturn Distribution are outlined on the attached notice.
	ASB Fund 2011 Benefit Payment Information Mon, Jan 10, 2011 For 2011 Benefits will continue to be paid by the Fund on a monthly basis, application for Benefit Forms are due in the Fund Office no later than the Fourth Tuesday of each calendar month for the subsequent month's Benefit payment. See attached letter for additional information. Click Here to download the document for the ASB Fund 2011 Benefit Payment Schedule.

	Patient Protection and Affordable Care Act Information Fri, Nov 19, 2010 Click Here to see attached Welfare Fund announcement letter for important information under the Patient Protection and Affordable Care Act.

	Patient Protection and Affordable Care Act Information (MES Helper) Thu, Nov 18, 2010 Click Here to see attached Welfare Fund announcement letter for important information under the Patient Protection and Affordable Care Act.

	Medicare Modernization Information/Prescription Drug Benefits (Part D) - Active Sun, Nov 14, 2010 Beginning November 15, 2010, all participants and qualified dependents of Plumbers Local Union No. 1 Welfare Fund who are either currently enrolled in Medicare or will be eligible to enroll in Medicare on or before December 31, 2010 will be offered the opportunity to: (1) Enroll with either the Medicare Prescription Drug Benefit (Part D) plan; or (2) Enroll with an equivalen Medicare Advantage Plan (private insurance companies); or (3) Continue to receive prescription drug benefits through the Plumbers Local Union No. 1 Welfare Fund.

	Medicare Modernization Information/Prescription Drug Benefits (Part D) - Retiree Sat, Nov 13, 2010 Beginning November 15, 2010, all participants and qualified dependents of Plumbers Local Union No. 1 Welfare Fund who are either currently enrolled in Medicare or will be eligible to enroll in Medicare on or before December 31, 2010 will be offered the opportunity to: (1) Enroll with either the Medicare Prescription Drug Benefit (Part D) plan; or (2) Enroll with an equivalen Medicare Advantage Plan (private insurance companies); or (3) Continue to receive prescription drug benefits through the Plumbers Local Union No. 1 Welfare Fund.

	Medicare Modernization Information/Prescription Drug Benefits (Part D) - MES Helper Fri, Nov 12, 2010 Beginning November 15, 2010, all participants and qualified dependents of Plumbers Local Union No. 1 Welfare Fund who are either currently enrolled in Medicare or will be eligible to enroll in Medicare on or before December 31, 2010 will be offered the opportunity to: (1) Enroll with either the Medicare Prescription Drug Benefit (Part D) plan; or (2) Enroll with an equivalen Medicare Advantage Plan (private insurance companies); or (3) Continue to receive prescription drug benefits through the Plumbers Local Union No. 1 Welfare Fund.
	11th Annual Employee Benefit Fair - SAVE THE DATE! Tue, Sep 14, 2010 When: Wednesday, October 20 3:00 p.m. to 6:30 p.m. Where: Plumbers Local Union No.1 Training Facility 37-11 47th Avenue, Long Island City. Click Here to view document.

	ASB Fund 2010 Benefit Payment Information Wed, Jan 13, 2010 For 2010 Benefits will continue to be paid by the Fund on a monthly basis, application for Benefit Forms are due in the Fund Office no later than the Fourth Tuesday of each calendar month for the subsequent month's Benefit payment. See attached letter for additional information. Click Here to view document.

	Get Healthy and Save $$$ in 2010 Wed, Dec 30, 2009 Did you know? Under your Welfare Fund benefits, you can get a prescription filled for as little as $2 when you use a generic medication. Click Here to view document.

	New Supplemental Vacation Benefit Form W4 Option Thu, Jul 30, 2009 The Trustees of the Vacation and Holiday Fund have approved changes to the Plan's income tax withholding for Supplemental Vacation Benefits. Specifically, Supplemental Vacation Benefits may be paid under the Form W-4 option similar to the Semi-Annual Automatic payments as described in the attached SMM#1. Click Here to view document.

	Supplemental Vacation Benefit Limits Fri, Apr 24, 2009 Effective April 1, 2009 Supplemental Vacation Benefit limits were increased from $1,500 to $3,000. You may also apply for Benefits four times a year effective May 1, 2009, twice in the period from January 1st through the first Tuesday in May and twice in the period from August 1st through the first Tuesday in October. Click Here to view document.

	ASB Fund Financial Market Impact Update Wed, Mar 18, 2009 Click Here to view document.

	MES Division Hourly Wage Reallocation Wed, Mar 4, 2009

	Building Trades Division Hourly Wage Reallocation Fri, Jan 23, 2009

	ASB Fund Financial Market Impact Letter Civil Service New Post Tax Account B Fri, Jan 9, 2009 Click Here to view document.

	ASB Fund Financial Market Impact Letter (Revised) Wed, Jan 7, 2009 Click Here to view document.