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Benefit Office Forms

Benefit Office Forms

  • Annuity Fund

  • Request For Disbursement Application Request For Loan Application Request For Systematic Installment Beneficiary Form Disbursement for Beneficiary - QDRO Form Death Beneficiary Claim Form Prudential Direct Deposit Form Prudential Rollover In Form
  • Pension Fund

  • Pension Application Pension Tax Withholding Form Pension Beneficiary Form Change of Address Form
  • Health & Welfare Fund

    • Medical Plan
      Excellus Medical Plan Generic Drugs Excellus Enrollment/Change Form Excellus HIPAA Authorization Form Excellus Sample Monthly Health Statement
    • Dental Plan
      Excellus Dental Blue Options
    • Life & Accidental Death & Dismemberment
      Basic Life and AD&D Highlights Benefit Assist Counseling Estate Guidance Funeral Planning Travel Assist
    • Employee Assistance Program
      Employee Assistance Program
    • Hour Bank Reimbursement
      Lifetime Benefit Solutions LBS Hour Bank Reimbursement Form LBS Online Portal LBS App Over-the-Counter Eligible Items
    • Medicare Members
      Local 13 Medicare Advantage Plans Excellus Medicare Enrollment Form
    • General Forms
      Member Personnel Record Advance Medical Eligibility Form Insurance Beneficiary Form Hour Bank Election Form Change of Address Form
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Local 13 Plumbers and Pipefitters
1850 Mt.Read Blvd.
Rochester, NY 14615
Phone: (585) 338-2360
Fax: (585) 544-3993

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