FORMS

Welfare Fund

	Beneficiary Designation Form
	Dental Claim Form
	Disability Benefits Application
	Health and Welfare Claim Form
	MOE Pharmacy Mail Service Order Form
	Family Supplemental Benefits Claim Form
	HIPPA Personal Representative Form
	MOE Flu Shot Voucher 2011

Enrollment Forms

	Custodial Parent Questionnaire
	Dependent Enrollment Form
	Determination Of Payment Liability Notice
	Employment and Prior Healthcare Questionnaire
	Family Medical History
	Pre-Exisitng Limitation Notice

Pension Forms

To request the following forms, call the Pension Fund at 708.579.6640 or click on the form name:

The information on this Web site presents selected highlights of the Midwest Operating Engineers Fringe Benefit Funds, the Health and Welfare Fund, and the Pension Fund. The actual Plan provisions of each Plan are in the Plan’s legal document. In the event of a conflict between the wording on this Web site and the legal documents, the legal documents will govern. The Trustees reserve the right to amend, modify, or discontinue all or part of any Plan at any time.