Welcome to the Welfare Fund Forms Section
With possible disruptions with the US Postal Services and limited access
to the Fund Office. All applications and related documents should bee
sent by e-Mail or Text to firstname.lastname@example.org or by fax to 718-641-8155.
Weekly Unemployment Benefit Form
- Forms must be submitted with ORIGINAL Signatures!
stating that your unemployment claim is being reviewed/processed are
insufficient when applying for this benefit. You must submit proof for
each week that you have collected/received State Unemployment Benefits.
- Local 1 Certification is required.
- Form W4 and Direct Deposit Authorization is Optional.
HRA Claim Form
HRA Payment Authorization Form
Change of Address Form
Extension of Eligibility Form - Unemployment
Extension of Eligibility Form - Return to Work
Extension of Eligibility Form - Disability
Weekly Disability Benefit Form
Beneficiary Designation Form
Special Enrollment Form (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
Hearing Aid Claim Form
Medicare Claim Form
Notarized Affidavit of Current Marriage
Welfare Fund ASB Account Application for Benefit Form
COBRA Form - ARP
You will need Adobe Acrobat Reader to view the above forms. If you do not have Acrobat Reader installed, you may download it here.