Accident & Sickness Claim Form - Operating Engineers Local 825 Welfare Fund printable pdf download

Accident & Sickness Claim Form - Operating Engineers Local 825 Welfare Fund

Date: __________________________________

Member: _______________________________

Member ID# ____________________________

Date of Accident/Illness: __________________

From: _________________________________

Dear Member:

We would appreciate your prompt attention to the items checked below:

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Please have the attached form completed in its entirety. We need the original form

returned to us in order to process your claim.

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Since our disability plan is a supplemental one, it is necessary that you provide us with

payment detail information. Please submit photocopies of your weekly state or private

plan disability or worker’s compensation check. You can fax this information to us at

973-671-6821.

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If your disability claim is determined to be eligible through the NJ State Plan, you will

need to provide the payment detail page of the ABSTRACT. There are 2 ways to gather

this:

For Disability While Employed, please call the Temporary Disability Benefits office at

609-292-7060 or access through the internet with the following steps:

Google- NJ Temporary Disability. Click on “Web Services.” Click on “Access Web

Inquiry” and create a new user name and password to view your claim. Once you enter

and view your claim, you will be able to print a payment detail page.

For Disability During Unemployment, please call 609-292-3842 to have an

ABSTRACT mailed to you. This is the only way to receive the abstract necessary to

process your application.

Please note: A new abstract needs to be submitted every time you are paid from the

State in order to process your supplemental disability benefits.

Accident & Sickness Claim Form - Operating Engineers Local 825 Welfare Fund