Forms Legal Notices and Disclosures | IRONWORKERS DISTRICT COUNCIL OF WESTERN NEW YORK AND VICINITY



Home Page About Us Plan Documents Forms, Legal Notices, and Disclosures Employer Information Medical Benefit Plan Information Locals that Belong to the District Council Benefits Employee Assistance Program (“EAP”) Allocations (Gains/Losses) Local 33 Members new Supplemental Fund/HRA Debit Mastercard	Forms, Legal Notices, and Disclosures This is your benefit forms library. Here you will find the forms you need to work with your various benefits. Just click on the link and a .pdf version of the form will appear in a separate window. You may then print the form to your local printer. Please complete and send to the Fund Office. If you have questions, please call us at (585) 424-3510. Thank You Welfare Supplemental Annuity WRA Pension Old Remittance Forms Old Wage Rate Sheets Other Telemedicine https://www.excellusbcbs.com/wps/portal/xl/find-doctor/telemedicine-facts Claim Forms BCBS Subscriber Claim Form SMM-IMPACT Disability IMPACT - Maternity Claim Form with ACH agreement IMPACT - Accident Claim Form with ACH agreement Express Scripts Prescription Drug Reimbursement Form Supplemental Disability Claim Form Other Forms COB / Enrollment Form Self Pay Premium Form Life Insurance Beneficiary Form / Prudential Insurance Authorization for Release of Health Information Accidental Death & Dismemberment Beneficiary Form / Welfare Fund Prudential Certificate of Coverage Legal Notices and Disclosures Prudential Life - Disclosures Prudential Accidental Death & Dismemberment (AD&D) HIPAA Privacy Notice Initial Notice of COBRA Coverage Special Enrollment Rights Women's Health and Cancer Act Request for Payment Reimbursement Form FILLABLE - Request for Payment Reimbursement Form Authorization Selfpay Option Authorization Automatic Rollover Form Authorization for Release of Health Information Updated Privacy Policy Annuity Cover Letter - 20% Withholding - July, August, September, & October Distributions Annuity Cover Letter Election Form Special Tax Notice Annuity Beneficiary Designation Form (All Locals) Annuity Benefit Application Annuity Hardship Withdrawal Application Annuity Hardship 2026 W4-R WRA Request Form WRA-Guardian Life & AD&D Beneficiary Form W-4 Form (2026) WRA Amendment Guardian Certificate of Coverage Guardian Accidental Death and Dismemberment Conversion Guardian Privacy Notice Direct Deposit Form Pre-retirement Death Benefit Beneficiary Form / Pension Fund Pension Direct Deposit Form W4-P Form 2026 Local 9 Apprentice Remittance Form - Effective 5/1/13 Apprentice Remittance Form - Effective 5/1/14 Apprentice Remittance Form - Effective 5/1/15 Apprentice Remittance Form - Effective 5/1/16 Apprentice Remittance Form - Effective 5/1/17 Apprentice Remittance Form - Effective 7/1/18 Apprentice Remittance Form - Effective 7/1/19 Journeyman Remittance Form - Effective 5/1/13 Journeyman Remittance Form - Effective 5/1/14 Journeyman Remittance Form - Effective 5/1/15 Journeyman Remittance Form - Effective 5/1/16 Journeyman Remittance Form - Effective 5/1/17 Journeyman Remittance Form - Effective 7/1/18 Journeyman Remittance Form - Effective 7/1/19 Local 12 Apprentice Remittance Form - Effective 5/1/13 Apprentice Remittance Form - Effective 5/1/14 Apprentice Remittance Form - Effective 5/1/15 Apprentice Remittance Form – Effective 5/1/16 Apprentice Remittance Form – Effective 5/1/17 Apprentice Remittance Form – Effective 7/1/18 Apprentice Remittance Form – Effective 7/1/19 Journeyman Remittance Form - Effective 5/1/13 Journeyman Remittance Form - Effective 5/1/14 Journeyman Remittance Form - Effective 5/1/15 Journeyman Remittance Form - Effective 5/1/16 Journeyman Remittance Form - Effective 5/1/17 Journeyman Remittance Form - Effective 7/1/18 Journeyman Remittance Form - Effective 7/1/19 Local 33 Apprentice Remittance Form - Effective 5/1/13 Apprentice Remittance Form - Effective 5/1/14 Apprentice Remittance Form - Effective 5/1/15 Apprentice Remittance Form - Effective 5/1/16 Apprentice Remittance Form - Effective 5/1/17 Apprentice Remittance Form - Effective 7/1/18 Apprentice Remittance Form - Effective 7/1/19 Journeyman Remittance Form - Effective 5/1/13 Journeyman Remittance Form - Effective 5/1/14 Journeyman Remittance Form - Effective 5/1/15 Journeyman Remittance Form - Effective 5/1/16 Journeyman Remittance Form - Effective 5/1/17 Journeyman Remittance Form - Effective 7/1/18 Journeyman Remittance Form - Effective 7/1/19 Local 60 Apprentice Remittance Form - Effective 5/1/12 Apprentice Remittance Form - Effective 5/1/13 Apprentice Remittance Form - Effective 5/1/14 Apprentice Remittance Form - Effective 5/1/17 Apprentice Remittance Form - Effective 7/1/18 Apprentice Remittance Form - Effective 7/1/19 Journeyman Remittance Form - Effective 5/1/12 Journeyman Remittance Form - Effective 5/1/13 Journeyman Remittance Form - Effective 5/1/14 Journeyman Remittance Form - Effective 5/1/17 Journeyman Remittance Form - Effective 7/1/18 Journeyman Remittance Form - Effective 7/1/19 Local 440 Apprentice Remittance Form - Effective 5/1/13 Apprentice Remittance Form - Effective 5/1/15 Apprentice Remittance Form - Effective 5/1/16 Apprentice Remittance Form - Effective 5/1/17 Apprentice Remittance Form - Effective 7/1/18 Apprentice Remittance Form - Effective 7/1/19 Journeyman Remittance Form - Effective 5/1/13 Journeyman Remittance Form - Effective 5/1/14 Journeyman Remittance Form - Effective 5/1/15 Journeyman Remittance Form - Effective 1/1/15 Journeyman Remittance Form - Effective 5/1/16 Journeyman Remittance Form - Effective 5/1/17 Journeyman Remittance Form - Effective 7/1/18 Journeyman Remittance Form - Effective 7/1/19 Local 9 Wage Rate Sheet - Effective 5/1/13 Wage Rate Sheet - Effective 5/1/14 Wage Rate Sheet - Effective 5/1/15 Wage Rate Sheet - Effective 5/1/16 Wage Rate Sheet - Effective 5/1/17 Wage Rate Sheet - Effective 7/1/18 Wage Rate Sheet - Effective 7/1/19 Local 12 Wage Rate Sheet - Effective 5/1/13 Wage Rate Sheet - Effective 5/1/14 Wage Rate Sheet - Effective 5/1/15 Apprentice Wage Rate Sheet - Effective 5/1/16 Apprentice Wage Rate Sheet - Effective 5/1/17 Apprentice Wage Rate Sheet - Effective 7/1/19 Apprentice Wage Rate Sheet - Effective 7/1/18 Journeyman Wage Rate Sheet - Effective 5/1/16 Journeyman Wage Rate Sheet - Effective 5/1/17 Journeyman Wage Rate Sheet - Effective 7/1/18 Journeyman Wage Rate Sheet - Effective 7/1/19 Notice of Rate Increase - Effective 5/1/17 Notice sent to Employers regarding change in administration of IW Local 12 contributions - Effective 1/1/2017 Local 33 Wage Rate Sheet - Effective 5/1/13 Wage Rate Sheet - Effective 5/1/14 Wage Rate Sheet - Effective 5/1/15 Wage Rate Sheet - Effective 5/1/16 Wage Rate Sheet - Effective 5/1/17 Wage Rate Sheet - Effective 7/1/18 Local 60 Wage Rate Sheet - Effective 5/1/14 Wage Rate Sheet - Effective 5/1/15 Wage Rate Sheet - Effective 5/1/16 Wage Rate Sheet - Effective 5/1/17 Wage Rate Sheet - Effective 7/1/18 Wage Rate Sheet - Effective 7/1/19 Local 440 Wage Rate Sheet - Effective 5/1/13 Wage Rate Sheet - Effective 5/1/14 Wage Rate Sheet - Effective 5/1/15 Wage Rate Sheet - Effective 5/1/16 Wage Rate Sheet - Effective 5/1/17 Wage Rate Sheet - Effective 7/1/18 Wage Rate Sheet - Effective 7/1/19 Change of Address Form Paid Family Leave Reciprocity Form Self Pay Premium Form