Use this form for the claims period of January 1, 2024 through June 30, 2024. The form must be completed, signed and submitted to the Fund Office by August 31, 2024 in order to receive benefit in October 2024.
Use this form for the claims period of July 1, 2023 through December 31, 2023. The form must be completed, signed and submitted to the Fund Office by February 28, 2024 in order to receive benefit in April 2024.
Complete this form authorizing the Boilermakers National Health and Welfare Fund to release premium reimbursement information to the Boilermakers Local 83 Supplemental Health and Welfare Fund
Complete this form authorizing the Boilermakers National Pension Fund to release work hours and contributions history to the Boilermakers Local 83 Supplemental Health and Welfare Fund.
Use this form to authorize the release of Protected Health Information, such as premium reimbursement information, from a carrier other than the Boilermakers National Health and Welfare Fund to the Boilermakers Local 83 Supplemental Health and Welfare Fund.