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 or anyone else, they also must fill out this form and return it to the Fund office.
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To enroll your dependent child for coverage under the Plan, submit a completed Dependent Child Enrollment Form or Information Verification Form along with a copy of the birth certificate or adoption papers to the Fund Office. If you are not married to your child’s birth mother/father, then you would also need to complete a Dependent Affidavit Form, have it notarized, and submit it to the Fund Office with any supporting documents. You must submit the completed enrollment form with the appropriate documentation to the Fund Office within 60 days of the event. If you do not enroll your dependent in 60 days, claims will be denied until you submit the required information.

Your birth child is eligible for coverage on the date of his or her birth. If you adopt a child, have a child placed with you for legal guardianship, or acquire a stepchild through marriage, he or she will be eligible for coverage on the date of placement or marriage, as long as you are responsible for healthcare coverage and your child meets the Plan’s definition of a dependent child.
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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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If you are not married to your child’s birth mother/father, then you need to complete this form, have it notarized, and submit it to the Fund Office with any supporting documents.
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If you are Retiring (or have Retired) and are receiving a monthly Pension check that is greater than your Welfare monthly premium amount, you may authorize Welfare to deduct this monthly premium from your Pension check or to be paid via monthly ACH withdrawal from you bank account by completing a Direct Payment Election Form.
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If you become disabled and are unable to work, you and your physician must complete this form and submit it to the Fund Office in order to receive the weekly Loss of Time (short-term disability) benefits.
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Once approved for the weekly Loss of Time (short-term disability) benefit, to continue to receive the benefit, you will be responsible to complete this Form.
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To sign up for direct deposit complete a Direct Deposit Form and return it to the Fund Office.
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To change the amount of the taxes withheld from your pension payment, complete a Tax Withholding Forms and return it to the Fund Office.
Federal W-4P Tax Withholding Form - Download
Missouri State W-4P Tax Withholding Form - Download
Kansas State K-4 Tax Withholding Form - Download

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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To designate a beneficiary for your account, you must fill out this form and return it to the Fund Office.
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