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Please complete this Enrollment Form and return it to the Fund Office.

Health Reimbursement Arrangement (HRA) Claim Form.

In order to be valid, this form must be completed, signed, and received by the Plan Administrator prior to the death of the Participant.

Heath Reimbursement Arrangement (HRA) Claim Form for Authorization of Automatic Monthly Premium or Retiree Premium Payments

Retiree Coverage Application

Please fill this form out to apply for short term disability benefits.

Designation of authorized representative and protected health information authorization form.

Vision care reimbursement form

Please fill out this form for a Delta Dental claim.

Debit Card Enrollment Form

Disability Direct Deposit Form

Subrogation Agreement and Questionnaire Concerning Insurance Coverage and Third-Party Responsibility.

Qualified Domestic Relations Order Policy.

Please complete this Enrollment Form and return it to the Fund Office.

Complete this form to request a change in contribution levels.

Complete this form to designate beneficiaries for the IBEW Local 347 Retirement and 401(k) Plan.

Complete this form for the following:

• request a rollover to an IRA with The Principal
• request a roll over to an IRA to another eligible retirement plan
• request a single cash payment from your retirement funds
• indicate that you choose to leave your retirement funds in your former employer’s plan
• to request regular income based on the annuity options under the plan

Complete this form to notify the IBEW Local #347 Retirement and 401 (K) Plan of your retirement

Please complete this form to provide a history of employment.

This form is to be completed by the beneficiary who is claiming benefits under this retirement plan. If there is more than one beneficiary, each must complete a separate Death Benefit Claim Form.