Please choose a form below to download.

Enrollment Form

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

Medical Claim Form

Please download this document to complete a Medical Claim Form

HRA Claim Form

Health Reimbursement Arrangement (HRA) Claim Form.

Beneficiary Designation 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.

HRA Monthly Premium Election Form

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

Application for Retiree Coverage

Retiree Coverage Application

Short Term Disability Report

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

PHI and Designated Rep Form

Designation of authorized representative and protected health information authorization form.

VSP Member Reimbursement Form

Vision care reimbursement form

LDI Claim Form

Pharmacy Services Reimbursement Claim Form

LDI Mail Order Form

Pharmacy Services mail order prescription form

Delta Dental Claim Form

Please fill out this form for a Delta Dental claim.

Subrogation Agreement and Questionnaire

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

QDRO Policy and Model

Qualified Domestic Relations Order Policy.

Please choose a form below to download.

Enrollment Form

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

Contribution Change Form

Complete this form to request a change in contribution levels.

Beneficiary Form

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

Distribution Application

    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

Statement of Retirement

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

Statement of Employment

Please complete this form to provide a history of employment.

Death Benefit Claim Form

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.

Statement of Hardship

Complete this form to provide notification that you have an immediate and heavy financial need

Hardship Application

Complete this form to withdraw part of your retirement funds while still employed.