Initial Weekly 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. Download

Continued Weekly 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 Corporation, to continue to receive Disability Credit Hours and Accident & Sickness Weekly Benefits. Download

Replacement Accident Letter:
If the Fund office, Wilson-McShane Corporation, 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. Download

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, Wilson-McShane Corporation. Download

Health Dynamics Claim Form:
Complete this form following your Health Dynamics physical to receive reimbursement for your co-pays and/or coinsurance or gym/health club membership. Download

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. Download

Health Care Directive Form:
Filling out a Health Care Directive form allows you to inform others of your health care wishes. You have the right to state your wishes or appoint an agent in writing so that others will know what you want if you can't tell them because of illness or injury. Having a health care directive ensures that your wishes regarding your health care are followed.

Health Care Directive Form for the state of Minnesota - Download

Health Care Directive Form for the state of North Dakota - Download

Health Care Directive Form for the state of South Dakota - Download

PHI Release Form:
Complete this form to authorize the Fund to release your Protected Health Information (PHI) to the persons, class of persons, or organization of your choice. Download

Beneficiary Designation Form:
Complete this form to name or update your beneficiary for the Plan's Death Benefit and Accidental Death & Dismemberment Benefit.
To request a Beneficiary Designation Form, Click here.

As a reminder, the Death Benefit is $8,000 for Active Employees and $2,000 for Retirees. The Accidental Death & Dismemberment Benefit Principal Sum is $8,000 for Active Employees and $2,000 for Retirees.

Change of Personal Information Form:
Complete this form to change or correct your mailing address and/or name. Download

Family Update Form:
Complete this form to update the Fund office, Wilson-McShane Corporation, of any changes regarding your dependents and their insurance coverage. Download

Dependent Affidavit (age 0-18):
Please complete this form to add coverage for your minor dependent (age 0-18) if your marital status is single or the dependent is a step-child. Download

Adult Child Enrollment Form (age 19-25):
Please complete this form to add coverage for your dependent (age 19-25) if your marital status is single or the dependent is a step-child. Download

Reciprocity Form:
If you’re a member of Local 49 who is working outside of Local 49’s jurisdiction you must complete this form to have your contributions transfer back to Local 49. For more information on reciprocity click here. Download

Vision Claim Form - Bloomington Office:
If you are serviced by the Wilson-McShane office in Bloomington, complete this form and attach the appropriate itemized receipts to access the Fund's vision benefit. Download

Vision Claim Form - Duluth Office:
If you are serviced by the Wilson-McShane office in Duluth, complete this form and attach the appropriate itemized receipts to access the Fund's vision benefit. Download