Welcome to the Welfare Fund Forms Section

With possible disruptions with the US Postal Services and limited access to the Fund Office. All applications and related documents should bee sent by e-Mail or Text to info@ualocal1funds.org or by fax to 718-641-8155.

Weekly Unemployment Benefit Form

• Forms must be submitted with ORIGINAL Signatures!
  
• Statements stating that your unemployment claim is being reviewed/processed are insufficient when applying for this benefit. You must submit proof for each week that you have collected/received State Unemployment Benefits.
• Local 1 Certification is required.
  
• Form W4 and Direct Deposit Authorization is Optional.
  

HRA Claim Form

HRA Payment Authorization Form

Change of Address Form

Extension of Eligibility Form - Unemployment

Extension of Eligibility Form - Return to Work

Extension of Eligibility Form - Disability

Weekly Disability Benefit Form

COBRA Form

Beneficiary Designation Form

Special Enrollment Form (Adult Child to Age 26)

Benefit Enrollment Form

Universal Enrollment Form

Text Message and Email Authorization Form

PHI Authorization Form

PHI Cancellation Form

Certification of Medical Necessity Form

Qualified Relative Certification Form

Dental Claim Form Out-of-Network

Vision Claim Form Out-of-Network

Hearing Aid Claim Form

Notarized Affidavit of Current Marriage

Welfare Fund ASB Account Application for Benefit Form

You will need Adobe Acrobat Reader to view the above forms. If you do not have Acrobat Reader installed, you may download it here.