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IBEW 292 BENEFITS
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Forms

Let’s take a look at
your benefit options.

Healthcare Forms

  • Enrollment For Adult Dependent Children​
  • Beneficary Form (All Plans)​
  • Spousal Coverage Verification​
  • Healthcare Plan Information Sheet (New Members)​
  • Authorization for Healthcare Plan
  • Healthcare Plan Information Sheet (Existing Members)​
  • Subrogation Agreement
  • Other Insurance Questionnaire​

Prescription Forms

  • Prescription Reimbursement

Employer Services Forms

  • 401k Deduction
  • Internet Shop Report
    (to receive a password to access this online report, call 763-493-8841)
  • ISSi-Remit Online Remittance Instructions

Vision Forms

  • Safety Eyeware
    Contact Benefits Office at (763) 493-8830
  • Reimbursement for Non-VSP Providers

Disability Forms

  • Loss of Time (Physician)
  • Loss of Time (Employee and Employer)
  • Loss of Time (Mental Health/Chemical Dep.)
  • Loss of Time Continuation Form
  • Loss of Time Info Sheet
  • Application for SUB Benefits and Disability

Defined Contribution & 401k

  • 401k Deduction
  • 401k QDRO (Qualified Domestic Relations Orders)
  • Beneficary (All Plans)

Pension Forms

  • Pension Pre-Retirement QDRO (Qualified Domestic Relations Orders)
  • Pension Post-Retirement QDRO (Qualified Domestic Relations Orders)
  • Pension Verification
  • Pension Income Tax Withholding

Subfund Forms

  • Application for SUB Benefits
  • Subfund Application Letter
  • Beneficary (All Plans)

Address Change Forms

  • Address Change

Vacation

  • Vacation and Holiday Plan Direct Deposit Authorization Form

Contact Us

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IBEW Local 292 Benefits Office
6900 Wedgwood Rd N, Ste 425
Maple Grove, MN 55311

P 763-493-8830
F 763-416-6196
View Our Privacy Policy

The Benefit Office receives the negotiated contributions sent to us by your contractors or other Locals. These contributions are what determine your eligibility for Health and Welfare and Retirement benefits. Each quarter that you work, you will receive a statement from the Benefit Office with your hours worked and contributions received. It is important that you keep your check stubs to make sure that all of your contributions are being reported correctly. In the event of an error or question, please call the Fund office. All products cited are copyrights of their respective owners.

IBEW Local 292 Benefits Office
6900 Wedgwood Rd N, Ste 425
Maple Grove, MN 55311

P 763-493-8830
F 763-416-6196
View Our Privacy Policy