Ironworkers Local 492 Reciprocal Form

Local 492 Reciprocal Request Notification

Fill out the form in its entirety to complete request
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address 2

CityState

Zip Code
E-mail
example@example.com
Mobile Number*
Format: (000) 000-0000.
Social Security Number*
Union Book Number*
Home Local Number*
Birth Date*

MonthDayYear
Date
I hereby elect or do not elect as indicated below, to have contributions that are paid on my behalf to the following Funds, transferred to my Home Funds. I understand that this authorization is only valid with respect to those cooperating funds that have executed agreements with my Home Fund to permit the transfer of contributions.
Elect to have my Health & Welfare contribution remitted to my Home FundDo Not Elect to have my Health & Welfare contribution remitted to my Home Fund & stay with Local 492 (Iron Workers of Tennessee Valley and Vicinity Welfare, Pension and Annuity Fund)
Elect to have my Pension contribution remitted to my Home FundDo Not Elect to have my Pension contribution remitted to my Home Fund & stay with Local 492 (Iron Workers of Tennessee Valley and Vicinity Welfare, Pension and Annuity Fund)
Elect to have my Annuity contribution remitted to my Home FundDo Not Elect to have my Annuity contribution remitted to my Home Fund & stay with Local 492 (Iron Workers of Tennessee Valley and Vicinity Welfare, Pension and Annuity Fund)
Local 492 Employer (Contractor)*
Jobsite Name*
Job Steward Name*
YesNo
Signature*

Powered by Jotform SignClear
Should be Empty:

Local 492 Reciprocal Request Notification