Forms

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Supplemental Health & Welfare Fund Claim Form [7/2023 to 12/2023]

  • 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.

    • 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.