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.


Adult Child Medical Coverage

PATIENT PROTECTION AND AFFORDABLE CARE ACT
Form for Eligible Employees with a child whose coverage ended, or who was denied coverage before attainment of age 26.


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. See Page 48 or (pdf page 58) of Welfare Fund Summary Plan Description Booklet


Request To Terminate Medical Coverage of a Conjunct Covered Dependent

FOR MEMBERS REPORTED MONTHLY
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.