Forms

Common forms for Members pertaining to Medical Benefits, Pension Benefits and Reciprocity. Mail, fax or Scan & Upload form(s) after completing and signing.


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Mail To:

Laborers' Combined Funds of Western PA

12 Eighth Street, Suite 500

Pittsburgh, PA 15222

Fax:

(412) 263-2813



Employee Identification Card

A member must fill out this form and provide appropriate documentation in order for his or her dependent(s) to receive benefits.


Medical Claim Form

Comprehensive Medical Claim Form


Prescription Claim Form

Prescription Drug Reinbursement Form


PPO Blue Enrollment Form

The optional Highmark PPO Blue Plan will include providers in the Highmark network, including UPMC, as in-network providers.


Highmark International Claim Form

Through the Blue Cross Blue Shield Global Core program, you have access to doctors and hospitals around the world.


Davis Vision Claim Form

Use this form to request reinbursement for services recieved from providers who do not participate in the Davis Vision Network.


Verification of New Covered Dependent Child

Fill out this form if you wish to cover a dependent and do not yet have a birth certificate, adoption documents or other documents required by The Welfare Fund.


Short Term Disability Form

A form for eligible members to apply for Short Term Disability when fully and continually disabled by a non-occupational disability.
Read more in the Welfare Summary Plan Description


Request To Terminate Medical Coverage of a Covered Dependent

A copy of a current insurance card for the terminating dependent is also required for all Conjunct employees.


IRS W-4P

WITHHOLDING CERTIFICATE FOR PENSION OR ANNUITY PAYMENTS
Form for specifying the amount of Federal Income Tax to Withhold from Pension Payments.


Direct Deposit for Pension Annuity

Form to have monthly pension amount directly deposited into bank account on the first business day of each month.


Disability Forms

MEMBER AND ATTENDING PHYSICIAN COMPLETE AND SIGN THESE FORMS ANNUALLY
Forms must be filled out annually to continue to receive Pension Disability.


Beneficiary Designation Change

PRINCIPAL FINANCIAL GROUP
Change of Beneficiary form for Pension Death Benefit.


Contact Information

This form is to be filled out by the Retiree or Surviving Spouse.


Contact Information for Guardianship of Power of Attorney

This form is to be filled out by the Guardianship or Power or Attorney.


Transfer Request and Consent Form

Form to authorize contributions paid on behalf of member to another fund be transferred to Laborers District Council of Western Pennsylvania Welfare and/or Pension Fund.