CONNECTICUT CARPENTERS BENEFIT FUNDS
10 BROADWAY, HAMDEN, CT 06518 | (203) 281-5511 | FAX (203) 288-3235 | (800) 922-6026

Members
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Employers
Login in here for access to the on-line contribution reporting system and receipts

Contribution Forms

NE Regional Council of Carpenters

Complete Forms On-Line---  Many but not all of the forms below may be completed on-line, printed and then mailed to the Funds.  To complete the forms on-line simply click on the desired form below and then click on the desired section(s) of the form you would like to complete and type in the desired information prior to printing. 

To view these forms Adobe Acrobat Reader must be installed on your computer.  If you do not currently have Adobe Acrobat, you may download a free version of the Adobe Acrobat Viewer by clicking on the link below.

Plan Booklets

Health Plan

Pension Plan

Annuity Plan

• Health Benefit Claim Form (316 Kb)

• Disability Claim Form (104 Kb)

• Authorization to Disclose Protected Health Information (126Kb)

• Appointment of Personal Representative Form (100Kb)

• COBRA General Notice (121Kb)

• COBRA Notice A (117Kb)

• COBRA Notice of Qualifying Event (82Kb)

• COBRA Notice of early Termination (84Kb)

• Reminder of Reimbursement Agreement (107Kb)

• Pension Application (210 Kb)

• Election for Income Tax Withholding (239 Kb)

• Request for Reciprocity of Hours or Contributions (110 Kb)

• Doctor's Statement for Disability (104 Kb)

• Direct Deposit Authorization (18 Kb)

Network Information
Provider Directory

• Application for Benefits (320 Kb)

• Summary of Withholding Options (104 Kb)

• Election for Income Tax Withholding (58 Kb)

• Voluntary Contribution Procedures and Election Form (138 Kb)

• Direct Deposit Authorization (18 Kb)

• Explanation of Forms of Payment (208 Kb)

• Authorization for Payment of Health Self-Pay from Fund (88 Kb)