ILWU-PMA BENEFIT PLANS FORMS

Please note, some forms are not available through our site. If there is no link, you may request any form to be sent by mail by calling the Benefit Plans main office at our phone number (415) 673-8500 or (888) 372-4598.

General Forms
Welfare Claim Forms
Welfare Enrollment Forms
Welfare Plan Comparisons and Summaries
Other Welfare Forms
Pension Applications
Pension Payment Change Forms
Other Pension Forms

All forms must be signed.

General forms

Authorization to Release Information
Beneficiary Designation Form - This form requires an original signature. The form you physically sign must be sent to the Benefit Plans.
Pensioner Change of Address
​Record Change Form, this form can be used to:

• Add/delete dependent
• Change address (Pensioners, please choose the "Pensioner Change of Address" Form)
• Change marital status
• Change name
• Change phone number

Welfare ClaimS Forms

Chiropractic Benefit Claim Form
Coastwise Indemnity Plan - Hospital, Medical, Surgical Benefits Claim Form (non-Medicare)
Coastwise Indemnity Plan - Hospital, Medical, Surgical Benefits Claim Form (Medicare)
Delta Dental Claim Form
Diabetic Durable Equipment Claim Form
Disability Benefits:

• CSDI Disability Supplement Claim Form
• Weekly Indemnity Benefits Claim Form
• Weekly Indemnity Benefits Supplementary Claim Form
• Weekly Indemnity Electronic Payment Authorization
• Welfare Eligibility Claim Form (To be Completed by JLRC Only)

Hearing Aid Claim Form
​Hearing Aid Claim Form - Kaiser OR Eligible
Opthamology Benefit Claim Form
Prescription Drug Claim Form
Social Security Supplementation Benefit Claim Form
​Subsequent Prosthetic Device Benefit Claim Form

Welfare ENROLLMENT Forms

Coverage Choice Forms (the correct form for you depends on your home port for active longshore workers, or where you live):

• Medical - CA/OR/WA
• Dental - CA Locals 10, 34, 75, 91, and Retirees and Survivors living in San Francisco Bay Area
• Dental - CA Locals 18, 34A (Stockton), 54, and Retirees and Survivors living in Northern California
• Dental - CA Locals 13, 26, 63, 94, and Retirees and Survivors living in Southern California
• Dental - CA Locals 29, 46, and Retirees and Survivors living in Southern California
• Dental - Portland/Vancouver, WA
• Dental - WA

Coastwise Indemnity Plan Enrollment Form
Dependent Child Certification Form
Kaiser Washington Employee Enrollment and Change Form (2022)
Important Notice Regarding Taxation
Kaiser California Enrollment/Change Form
Kaiser Oregon Dental/Medical Enrollment Form
Kaiser Senior Advantage Enrollment Form (Northern CA)
​Kaiser Senior Advantage Enrollment Form (Southern CA)
Kaiser Senior Advantage Enrollment Form (WA)
Kaiser Senior Advantage Enrollment Form (OR)
Kaiser Senior Advantage Disenrollment Form (CA, OR, WA)​
​Worksheet 1, IRS Publication 501

Welfare Plan Comparisons and Summaries

Health Plan Comparison - CIP and Kaiser Washington (WA)
​Health Plan Comparison - CIP/Kaiser (CA/OR)
Health Plan Summary - Kaiser Washington Group Medicare Advantage HMO Plans
Health Plan Summary - Kaiser Washington for Actives
Health Plan Summary - Kaiser Washington for Retirees

Other Welfare Forms

Agreement to Reimburse Benefits
Coastwise Indemnity Plan Schedule of Allowances
HIPAA - Authorization for Use and/or Disclosure of Protected Health Information (PHI)
HIPAA - Designation of Personal Representative

Pension Applications

​Disability Retirement Checklist with Packet​

• Disability Retirement Application
• Disability Retirement Medical Report

Normal Retirement Checklist with Packet

• Normal Retirement Application

Pension Payment Change Forms

Direct Deposit Form (Electronic Fund Transfer) - For direct deposit of your pension benefit
Election Form - Federal - To set the amount of Federal taxes taken from your pension benefit
Election Form - State of California - To set the amount of California state taxes taken from your pension benefit
Notice to Pensioners re Income Tax Withholding

OTHER PENSION Forms

Pension Disability Submittal Claim Form
​Pensioner Change of Address
Authorization To Release Information