Site Map Icon
RSS Feed icon
 

Content on this page requires a newer version of Adobe Flash Player.

Get Adobe Flash player

 
 
August 16, 2017

IAFF Local Newswire
 
Join the Newswire!
Updated: Aug. 16 (15:59)

KCFD Retired Fire Fighters
IAFF Local 42
Laconia Golf Tournament
Professional Fire Fighters of New Hampshire
UNION BBQ
IAFF 3711
Bellows Falls L4437 Layoffs
Professional Fire Fighters of Vermont
Residents speak out at city council meeting against dog shooting
IAFF Local 1164
Local 42 Hosts IAFF Peer Support Training
Missouri State Council of Fire Fighters
 
     
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
Copyright © 2017, All Rights Reserved.
Powered By UnionActive™

98536 hits since Sep 23, 2008
Visit Unions-America.com!

Top of Page image