Forms

HEALTH & WELFARE FORMS

• Enrollment Card
• Annual Claim Form
• 19-26 Adult Children Claim Form
• Subrogation Agreement
• Direct Deposit Authorization Form
• Disability Forms (must be completed and signed by the Physician)
• Disability W-4 Form (must be completed and returned with the disability form)
• HRA Claim Form
• Cobra Election Form
• Dependent Primary Insurance Form
• Change of Address
• Injury Report
• Website Opt-In Form

PENSION FORMS

• Defined Benefits (Pacific Mutual) Forms
• Defined Contribution Application
• Direct Deposit Authorization Form
• Distribution Schedule (75% Letter)
• Distribution Forms
• FW4R – IRS Form
• FW4P – IRS Form
• Wage Deferral Enrollment (in progress)