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June 15, 2019

IAFF Local Newswire
 
Join the Newswire!
Updated: Jun. 15 (12:01)

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MERP

WASHINGTON STATE COUNCIL OF FIRE FIGHTERS

EMPLOYEE BENEFIT TRUST

Premium Reimbursement Plan Trust Office
3400 -188th Street SW, Suite 601
Lynnwood, WA  98037
  (425) 771-7359   (425) 771-1226
 

INFORMATION

 


 

Name:_____________________________________________________________________________
                               Last                                                              First                                                              MI

 

Address: __________________________________________________________________________
                               Street                                                                              City                               State           Zip

 

Soc.Sec#_____________________________Birthday:___________________Martial Status:________

Employer Name:_____________________________________Employment Start Date:_____________

Local Number:_______________________________________Effective Date on Plan:______________

Spouse:____________________________________________Birthday:_________________________
(if domestic partner, attach domestic partner affidavit)

Dependents:________________________________________Birthday:_________________________

                       ________________________________________Birthday:_________________________

                       ________________________________________Birthday:_________________________

                       ________________________________________Birthday:_________________________

                       ________________________________________Birthday:_________________________

                       ________________________________________Birthday:_________________________

If you have additional dependents, list their name(s) and birthday (s) on the back of this form.

Pursuant to the confirmation election of my local union, my employer will contribute an amount as specified in the local's collective bargaining agreement on my behalf to the WSCFF Premium Reimbursement Plan.

____________________________________________________                  ______________________
Signature of Participant                                                                                                          Date Signed
 

 
 
IAFF Local 804
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