Forms

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Supplemental Health & Welfare Fund Claim Form [7/2020 to 12/2020]

  • Use this form for the claims period of July 1, 2020 through December 31, 2020.  The form must be completed, signed and submitted to the Fund Office by February 28, 2021 in order to receive benefit in April 2021.
  • Supplemental Health & Welfare Fund Claim Form [1/2020 to 6/2020]

  • Use this form for the claims period of January 1, 2020 through June 31, 2020.  The form must be completed, signed and submitted to the Fund Office by August 31, 2020 in order to receive benefits in October 2020.
  • Supplemental Health & Welfare Fund Claim Form [7/2019 to 12/2019]

  • Use this form for the claims period of July 1, 2019 through December 31, 2019.  The form must be completed, signed and submitted to the Fund Office by February 28, 2020 in order to receive benefit in April 2020.
  • Boilermakers National Health and Welfare Fund Authorization For Release of Protected Health Information

  • 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
  • Boilermakers National Pension Fund Authorization For Release of Protected Health Information

  • 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.
  • Authorization For Release of Protected Health Information

  • 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.