IW 118 Reciprocal Agreement Enrollment

Reciprocal Agreement Enrollment Form
California Ironworkers Field Welfare Plan
California Ironworkers Field Pension Trust
California and Vicinity Field Ironworkers Annuity Fund

(800) 527-4613
131 No. El Molino Ave Suite 330
Pasadena CA 91101
Name*

First NameMiddle InitialLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security No.*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Home Local No.*
I hereby acknowledge that I have received and reviewed the schedules of benefits and regulations of the California Field Ironworkers Welfare Plan, Pension Trust and Annuity Fund and understand that this election may not ultimately be to my advantage. This form must be signed and returned to the Trust Fund office within 90 days from date of commencing work in this plan's jurisdiction.
Effective Work Month*
WORK MONTH NOT TO EXCEED 90 DAYS FROM DATE OF SIGNATURE
Election

Check all that apply
WELFARE
Home Local
Fund Name
Fund Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PENSION
Home Local
Fund Name
Fund Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ANNUITY
Home Local
Fund Name
Fund Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
"In accordance for the agreement to transfer to my Home fund contributions made on my behalf, I hereby release the Funds, and the Trustees of the California Field Ironworkers Trust Funds from any and all obligations, claims, demands, and liability resulting from my request to transfer monies to my Home fund. I further waive any claim or right to any benefits I may have had or asserted under the above Funds."
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Reciprocal Agreement Enrollment Form

Election