Disability Benefit Application Carpenter printable pdf download

CARPENTER FUNDS ADMINISTRATIVE OFFICE

OF NORTHERN CALIFORNIA, INC.

265 Hegenberger Road, Suite 100

P.O. Box 2280 Oakland, California 94621-0180

Tel. (510) 633-0333  (888) 547-2054  Fax (510) 633-0215



Carpenters Health and Welfare Trust Fund for California

Carpenters Pension Trust Fund for Northern California

Disability Benefit Application

Complete this form to apply for Temporary Disability Benefits, including:

•

An Extension of Health Coverage,

•

Supplemental Weekly Disability Benefits, and

•

Future Service Eligibility Pension Credit for Periods of Temporary Disability

This form must be submitted with the required proof of ALL Temporary Workers’ Compensation or State Disability

payments showing the disability dates paid, and must be submitted within 12 months of the onset of Disability. See

reverse for eligibility requirements.

Name: _________________________________ Participant ID, UBC, or Social Security #:________________________

Address: __________________________________________________________________________________________

NUMBER AND STREET

CITY

STATE

ZIP CODE

Telephone Number: (____) _______________________

Birth Date: ________________________________________

Date of Injury: ________________________________

First full day of Disability: ___________________________

Name of last Employer: __________________________

Date last worked prior to this disability: _________________

Did you return to work at any time during this disability?

Yes

If yes, when? ____________________

If your last date of Covered Employment was more than 3 days prior to the start of disability payments, please explain the

date gap between your last day worked in Covered Employment and your disability start date in the space provided. If

additional space is needed, attach a separate sheet. _________________________________________________________

__________________________________________________________________________________________________

Type of Temporary Disability Payments Received:

Workers’ Compensation

Temporary payments have been paid from: ______________ to _____________

State Disability Insurance (SDI)

Longshoremen’s & Harbor Workers’ Compensation

Please attach proof of payment from disability carrier in the form of check copies or check stubs showing the Disability

periods paid.

Have you applied for:

A Social Security Disability Award?

Yes

If yes, date applied: _________________

A Carpenters Pension?

Yes

If yes, date applied: _________________

Carpenters Pension Disability Certification for Future Service Eligibility Credits

A Participant may be granted Future Service Eligibility Credit for periods of absence immediately following Covered

Employment if temporary disability benefits have been paid by State Disability Insurance (SDI), Workers’ Compensation

or Longshoremen’s and Harbor Workers’ Compensation. In order to be granted this type of credit you must provide proof

of final payment from either SDI or Workers’ Compensation. (In the case of Worker’s Compensation you will be asked to

provide a letter from the Workers’ Compensation carrier listing beginning and ending dates of temporary payments.)

In the event that I am granted a Disability Pension retroactively, I authorize the Carpenters Pension Trust Fund for

Northern California to deduct from my retroactive Disability Pension Payments and forward the amount owed to the

Carpenters Health and Welfare Trust Fund for California any overpayments made under the Supplemental Weekly

Disability Benefit.

THE ABOVE ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

__________________________________________________________________________________________________

PARTICIPANT SIGNATURE

DATE

NOTICE: It is illegal to file a false or fraudulent claim or to knowingly help someone else file one. You may be fined or sent to prison for doing

so. You may also be required to pay civil damages.

Disability Benefits 10/2015

Disability Benefit Application Carpenter

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