Indiana Laborers Fringe Benefit Funds

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

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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

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

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