Enrollment and Update Forms:
Family Update Form for Plasterers, Cabinet Makers and Industrial Carpenters with Family Coverage:
If you want your spouse and/or Dependent child(ren) to have coverage from the Plan, you must fill out
this form and return it to the Fund Office. Only Dependents listed on this Enrollment Form will have
coverage from the Plan.
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Family Update Form for Industrial Carpenters with Single Coverage:
If you want your Dependent child(ren) to have coverage from the Plan,
you must fill out this form, include payment and return it to the Fund Office within 30 days
of when you first become covered under the Plan.
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Beneficiary Designation Form:
To designate a beneficiary for your death benefit, you must fill out this form and return it to the Fund Office.
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Change of Address Form:
Complete this form to change or correct your mailing address.
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Change of Name Form:
Complete this form to change or correct your Name.
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Member & Dependent Authorization Forms:
PHI Release Form:
If you want the Plan to disclose your protected health information to another individual(s),
persons, class of persons, or organization of your choice (for example, your spouse), you must
fill out this form and return it to the Fund Office. If your spouse and/or Dependent child(ren)
over the age of 17 (i.e. Dependent child(ren) who are at least 18 years old) want the Plan to
disclose their protected health information to you, they also must fill out this form and return
it to the Fund Office.
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Reciprocity Form:
This form is for Plasterers who worked out of the area who are affiliated with Local Unions participating in the Plasterers and Cabinet Makers Health Fund.
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Claims Form:
Initial Report of Claims Form:
If your provider does not automatically submit your bill to the Fund office, Wilson-McShane Corporation,
please complete this form and return it to the Fund office with the appropriate itemized bills.
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Initial Disability Claim Form:
If you become disabled and are unable to work, you and your physician must complete this form and submit
it to the Fund office, Wilson-McShane Corporation, in order to receive Disability Credit Hours and Accident &
Sickness Weekly Benefits.
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Supplementary Disability Claim Form:
If your disability period extends beyond the date your physician estimated you would be able to return to work
(listed on your Initial Disability Claim Form/previous Supplementary Disability Claim Forms), you and your
physician must complete this form and submit it to the Fund office, Wilson-McShane.
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Replacement Accident Letter:
If the Plan Administrator, Wilson-McShane, receives a claim that appears to be the result of an accident or an injury,
a letter requesting additional information will be sent to your address. Wilson-McShane is unable to process the claim
until the requested information is received. Complete this form if you misplaced or did not receive the original
accident letter and the requested information is still outstanding.
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Subrogation & Reimbursement Agreement:
Complete this form to acknowledge the Fund's subrogation and reimbursement interests.
For more information regarding subrogation and reimbursement, please contact the Fund Office.
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