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Important Active Participants Forms:



Forms for Download

Click on any of the links below to download that form:


  • - Accident & Disability Claim Forms:

    Click here to view and download the forms that apply if you become disabled and/or unable to work due to an accident.

    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

  • - Claim Forms:

    Click here to view and download the standard claim form and the Health Dynamics claim form.

    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 Directive and PHI Release Form:

    Click here to view and download the health care directive form that applies to the state you reside in and the Personal Health Information Form.

    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

  • - Member & Dependent Update & Authorization Forms:

    Click here to view and download claim forms you will need if you have a change of address or have changes regarding your dependents and insurance coverage.

    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 Address Form:
    Complete this form to change or correct your mailing address. Download

    Change of Name Form:
    Complete this form to change or correct your 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:

    Click here to view and download a Reciprocity Form.

    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 Forms:

    Click here to view and download the Active Participant Vision Reimbursement Claim Forms.

    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

How do I...

  • Request a Beneficiary Designation Form Click here for instructions on how to Request a Beneficiary Designation Form...

  • Add a dependent? Click here for instructions on how to Add a dependent...

  • Change my address? Click here for instructions on how to change your address...

  • File a claim for vision/hearing benefits? Click here for instructions on how to file a claim for vision/hearing aids...

  • Access my HRA? Click here for instructions on how to access your HRA...

  • Get reimbursed for my gym/health club membership or co-pays and/or coinsurance after I have a Health Dynamics physical? Click here for instructions on how to get reimbursed...

  • File for disability benefits? Click here for instructions on how to file for disability benefits...

  • Find a network provider? Click here for instructions on how to find a network provider...

  • How does a Medicare Retiree file a claim for vision/hearing? Click here for instructions on how a Medicare Retiree participant files a claim for vision/hearing...

  • Working outside of Local 49's jurisdiction and need your Health and Pension hours sent back to Local 49? Click here to view the reciprocity process to transfer your contributions from one Fund to another if you’re working in another area other than your home local...

Quick Links

  • HRA
  • Medical
  • Medicare Retiree
  • Vision
  • Health Reimbursement Arrangement (HRA) Summary Letter Download the Health Reimbursement Arrangement (HRA) Summary Letter

  • Qualified and Non-Qualified Health Reimbursement Arrangement (HRA) Expenses Qualified and Non-Qualified Health Reimbursement Arrangement (HRA) Expenses

  • HRA Claim Form Download an HRA Claim Form

  • HRA Election Change Form (OFF) Download the HRA Election Change Form (OFF)

  • HRA Election Change Form (ON) Download the HRA Election Change Form (ON)

  • Application for Enrollment for Dependent Child Download the Application for Enrollment for Dependent Child

  • Change of Address Form Download the Change of Address Form

  • Change of Name Form Download the Change of Name Form

  • Family Update Form Download the Family Update Form

  • Beneficiary Designation Form Request a Beneficiary Designation Form

  • Health Dynamics Claim Form Download the Health Dynamics Claim Form

  • Initial Weekly Disability Claim Form Download the Initial Disability Claim Form

  • Continued Weekly Disability Claim Form Download the Supplementary Disability Claim Form

  • Initial Report of Claims Form Download the Initial Report of Claims Form

  • PHI Release Form Download the PHI Release Form

  • Reciprocity Agreement Form Download the Reciprocity Agreement Form

  • Replacement Accident Letter Download the Replacement Accident Letter

  • Retiree Dental Plan Enrollment Form Download the Retiree Dental Plan Enrollment Form

  • Subrogation & Reimbursement Agreement Download the Subrogation & Reimbursement Agreement

  • Application for Enrollment for Dependent Child Download the Application for Enrollment for Dependent Child

  • Change of Address Form Download the Change of Address Form

  • Change of Name Form Download the Change of Name Form

  • Direct Payment ACH Debit Authorization Form Download the Direct Payment ACH Debit Authorization Form

  • Family Update Form Download the Family Update Form

  • Medicare Part B Enrollment Notification Download the Medicare Part B Enrollment Notification

  • PHI Release Form Download the PHI Release Form

  • Retiree Dental Plan Enrollment Form Download the Retiree Dental Plan Enrollment Form

  • Retiree Dental High Plan Summary Download the Retiree Dental High Plan Summary

  • Retiree Dental Standard Plan Summary Download the Retiree Dental Standard Plan Summary

  • 2015 Retiree Dental Plan Summary Plan Description (SPD) Download the 2015 Retiree Dental Plan Summary Plan Description (SPD)

  • Vision and Hearing Reimbursement Claim Form for Medicare Retirees Download the Vision and Hearing Reimbursement Claim Form for Medicare Retirees

  • Vision Claim Form - Bloomington Office Download the Vision Claim Form - Bloomington Office

  • Vision Claim Form - Duluth Office Download the Vision Claim Form - Duluth Office

Contact Us:
  • Wilson-McShane Office
  • Fund Coordinator
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