NW Plumbers & Pipefitters Health Fund AUTHORIZATION TO TRANSFER FRINGE BENEFIT CONTRIBUTIONS

AUTHORIZATION TO TRANSFER FRINGE BENEFIT CONTRIBUTIONS

TO BE FILLED IN BY TRAVELING MEMBER AND GIVEN TO OUTSIDE LOCAL UNION

This form is being completed by the:*

LocalMember

Name*

First NameMiddle InitialLast Name

SSN*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState

Zip Code

as a member of U.A. Local #:*

2644Other

visiting Local #:*

2644Other

Provide Home Local #*

Provide Visiting Local #*

Home Local

Visiting Local

I hereby authoize, if applicable, transfer to my home local trust contributions for me (check box or boxes):

Seattle Area Plumbing and Pipefitting Industry Health and Welfare Trust - U.A. Local 32 Health Plan

Mail Employer Billing to:

WA State Plumbing and Pipefitting Trust Office
C/O BeneSys Inc.
P.O. Box 88970
Tukwila, WA 98188

NW Plumbers & Pipefitters Health Fund - U.A. Local 44 and 26 Health Plan

Mail Employer Billing to:

Attn: Control Department
WPAS
P.O. Box 34203
Seattle, WA 98124-1203

Washington State Plumbing and Pipefitting Industries Pension Plan (Defined Benefit Plan) - U.A. Local 26, 32, 44, 598

Mail Employer Billing to:

WA State Plumbing and Pipefitting Trust Office
C/O BeneSys Inc.
P.O. Box 88970
Tukwila, WA 98188

Western Washington U.A. Supplemental Pension Plan (Defined Contribution Plan) - U.A. Local 26, 32, 44

Mail Employer Billing to:

WA State Plumbing and Pipefitting Trust Office
C/O BeneSys Inc.
P.O. Box 88970
Tukwila, WA 98188

Other

Name of Home Trust*

Phone Number*

Please enter a valid phone number.

Trust Address*

Street Address

Street Address Line 2

CityState

Zip Code

I agree to release my Home Trust Funds and any visited Trust Funds free and harmless of any and all claims or damages which these Trust Funds might incur as a result of transferring any monies as authorized by me. I agree that if no contributions are made to the National Pension Plan in any visited area, that a portion of the funds received by my Home Pension Fund may be transferred to the National Pension Plan.

Signature of Member*

Date

FORM MUST BE COMPLETED - INVALID IF NOT SIGNED

Copies of the completed form should be distributed to:

Home Local
New Local
Benesys
WPAS

Notification Sender

Sender Email

example@example.com