Forms

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Supplemental Health & Welfare Fund Claim Form [1/2025 to 6/2025]

  • Use this form for the claims period of January 1, 2025 through June 30, 2025.  The form must be completed, signed and submitted to the Fund Office by August 31, 2025 in order to receive benefit in October 2025.

    • Supplemental Health & Welfare Fund Claim Form [1/2024 to 6/2024]

  • 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.

    • 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.