D.A. Townley  -  Plan Administrators Iron Workers Union Local 97 International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers 
 

health
benefits

        
 
 
 
 
 
 
 
 
 
 
 
 
   
        
   
 
 
 
 
   
 
 
 
 
   
 

Weekly Indemnity Claim

Use
You've become disabled (through injury or sickness) and are no longer able to work. Use the Weekly Indemnity Benefits Claim form to make your claim for Weekly Indemnity benefits.


Information Needed to Complete the Form
Your personal Member information is needed to complete the form. In addition, information such as:

  • details of the sickness and/or accident,
  • an authorized union signature,
  • details of any other disability benefits to which you are entitled, and
  • the attending physician's statement and signature
is also required.

Please follow the instructions on the form.


Notes
  • Your claim must be filed within 30 days of becoming disabled.
  • Both your union and your doctor must complete their sections of the form before the claim will be considered.
  • The Member must sign on both pages of the form.
Questions on completing the form should be directed to the Plan Administrator.

Completed forms should be sent to the Plan Administrator.


 

Form Link
Weekly Indemnity Benefits Claim Form
Wage Indemnity Income Tax Form
 

Related Links
Weekly Indemnity Benefit Information
 
 
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