Indiana Laborers Fringe Benefit Funds

Indiana Laborers Fringe Benefit FundsIndiana Laborers Fringe Benefit FundsIndiana Laborers Fringe Benefit Funds

812-238-2551

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    • Home
    • member login
    • FORMS
    • Health Benefits
    • Retirement Benefits
    • WELFARE FUND NOTICES
    • employer portal
    • Delinquent Contractors

812-238-2551

Indiana Laborers Fringe Benefit Funds

Indiana Laborers Fringe Benefit FundsIndiana Laborers Fringe Benefit FundsIndiana Laborers Fringe Benefit Funds
  • Home
  • member login
  • FORMS
  • Health Benefits
  • Retirement Benefits
  • WELFARE FUND NOTICES
  • employer portal
  • Delinquent Contractors

Welfare Fund FORMS

ACCIDENT INFORMATION FORM (pdf)Download
ANTHEM MEDICAL CLAIM FORM (pdf)Download
CHANGE OF ADDRESS FORM-FILLABLE FORM (pdf)Download
COORDINATION OF BENEFITS FORM (pdf)Download
DEPENDENT CUSTODY FORM (pdf)Download
DEPENDENT ENROLLMENT FORM (CLASS A ACTIVE COVERAGE) (pdf)Download
HIPAA AUTHORIZATION FORM (pdf)Download
LEGAL REPRESENTATIVE REQUEST (pdf)Download
LEGALLY MARRIED SPOUSE AFFIDAVIT (pdf)Download
LOSS OF TIME APPLICATION (pdf)Download
LOSS OF TIME CONTINUATION FORM (pdf)Download
OPT-OUT FORM FOR SPOUSE OR DEPENDENT (pdf)Download
SUBROGATION FORM (pdf)Download

Pension Fund FORMS

30 DAY WAIVER 2023 (pdf)Download
CHANGE OF ADDRESS FORM-FILLABLE FORM (pdf)Download
Direct Deposit Form (pdf)Download
Federal Tax (Form W-4P) (pdf)Download
Proof of Age Document Request (pdf)Download
State Tax (Form WH-4P) (pdf)Download
Suspendible Employment Language (pdf)Download
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Indiana Laborers Fringe Benefit Funds

413 Swan Street, Terre Haute, Indiana 47807, United States

812-238-2551

Copyright © 2023 Indiana Laborers Fringe Benefit Funds - All Rights Reserved.


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