IBEW Local 43 FUNDs Office

Forms

For security purposes, most forms are placed behind a login portal. You can find the form you need here, then click the associated link to login and access.

=Notary Required

=Direct Link

=Benefit Portal

What - click to get:

Type:

Welfare Summary Plan Description - PDF

Welfare Summary Plan Description - Flipbook

Welfare Summary of Material Modifications

2026 Summary of Benefits & Coverage (SBC)

2025 Summary of Benefits & Coverage (SBC)

No Surprise Act Balance Billing Notice

Welfare Beneficiary Form

HIPAA Form

Welfare Privacy Notice

Initial COBRA Notice to Employees, Spouses and Dependents

Notice of Grandfathered Health Plan

What - click to get:

Type:

UMR Enrollment Form

Opt Out Waiver of Participation Form

Spousal Affidavit

HRA Reimbursement Claim Form

HRA Direct Deposit Form

HRA Letter of Medical Necessity Template

What - click to get:

Type:

Delta Dental Microsite - Includes Summary of Benefits

Delta Dental Annual Privacy Notice

Delta Dental Out of Network Claim Form

What - click to get:

Type:

EyeMed Out of Network Claim Form

What - click to get:

Type:

Medicare Advantage - Humana Enrollment Form

Medicare Advantage - Retiree Health Declination Form

Medicare Advantage - Humana PPO Plan Guide

What - click to get:

Type:

2025 Progyny Member Guide

What - click to get:

Type:

Bree Health Member Guide

Basic Budgeting Plan US

Budgeting-Basics-Toolkit

What - click to get:

Type:

Pension Summary Plan Description

Pension Summary of Material Modifications

Pension Beneficiary Form

Pension Direct Deposit Form

Pension Verification Form

Form W4-P (Federal Tax Form)

IT-2104-P (NYS Tax Form)

What - click to get:

Type:

Annuity Summary Plan Description

Annuity Summary of Material Modifications

Annuity Beneficiary Form

Annuity Work Affidavit

What - click to get:

Type:

Separation of Service Form

Loan Packet & Form

Rollover In Form

Required Minimum Distribution (RMD) Form

Installment Payment Form

Hardship Withdrawal Form

Disability Withdrawal

Forms

For security purposes, most forms are placed behind a login portal. You can find the form you need here, then click the associated link to login and access.

Participants

Welfare Fund

General Form

Medical Plan & HRA

Dental

Vision

Medicare Advantage

Progyny

Employee Assistance

Pension Fund

General Forms

Tax Forms

Annuity

General Forms

Receiving Benefits