Health and Welfare Fund – Forms/Notices

Due to the “stay-at-home” mandate as a result of COVID-19 and to protect our members and Fund Office staff, members must call the Fund Office first and refrain from visiting the Fund Office. All non-essential appointments are either being handled through a phone call or re-scheduled to a later date. If you need any documents notarized, please read the Executive Order signed by Governor J.B. Pritzker. Thank you for your patience and understanding.

FORMS – If you are unable to access any of the following forms, please contact the Fund Office to request the specific form(s) you need.

Reciprocity

Transfer Forms

Change of Address

If you recently moved, please login to your www.My150.com account to easily update your address by clicking on your My Profile. By updating your address on My150 all Local 150 entities will be notified of your updated address (i.e., District Office, Apprenticeship Training, Fund Office, etc.). Alternatively, you can complete the following Change of Address Form and submit the form to the Fund Office.

Change of Address Form

OHC Forms

Flu Shot Form

VOYA Financial

The following form is used to update the MCL $10,000 basic death benefit (for members only) and for the Supplemental Life Insurance. Once the form is completed, please mail to:

Kocher Insurance Group, Inc.
ATTN: Will McCabe
1165 N. Clark Street, 7th Floor
Chicago, IL 60610

VOYA Beneficiary Designation Form

Welfare Fund Forms

Welfare Fund Appeal Request Form
Accidental Dismemberment Benefit Claim Form
Active Employee Death Benefit Beneficiary Designation Form
- This form is only for active members that die prior to retirement. If you are a retired member and you are eligible for the Post-Retirement Lump Sum Death Benefit of $10,000, you must contact the Retirement Services Group at (708) 579-6630 to request a new beneficiary designation form.
Disabled Dependent Eligibility Review Form
Disability Claim Instructions and Forms
Health and Welfare Claim Form
Electronic Consent Form
Family Supplemental Claim Form
Changes to Privacy Notice and Forms/Personal Representative Form – please update your PHI pin through My150 (www.my150.com)
If you do not have a My150 account, please click here and complete the attached Personal Representative Form to update your PHI pin
Retiree Medical Savings Plan (RMSP) Claim Form
Retiree Medical Savings Savings Plan (RMSP) Beneficiary Form – Please submit this information to the Member Services Department at the Fringe Benefit Funds Office