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IBEW 292 BENEFITS
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  • BENEFITS
  • FORMS
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  • CONTACT
    • BOARD OF TRUSTEES
    • STAFF
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  • PRIVACY
  • LINKS
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Forms

Let’s take a look at
your benefit options.

Healthcare Forms

  • Beneficary Form (All Plans)​
  • Subrogation Agreement
  • Employer Verification of Uninsured Spouse
  • Authorization for Release of Health Information

Medical Claims/Prescription Forms

  • 2024 Medical Claim Reimbursement Form
  • 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 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 Income Tax Withholding MN
  • Pension Income Tax Withholding Federal
  • QDRO Template Pension Plan (Separate Interest)

Subfund Forms

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

Address Change Forms

  • Address Change

Vacation and Holiday Plan

  • Direct Deposit Authorization Form (Contact the IBEW 292 Benefits Office)

Contact Us

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IBEW Local 292 Benefits Office
6700 W. Broadway Ave
Suite B
Brooklyn Park, MN 55428

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
6700 W. Broadway Ave
Suite B
Brooklyn Park, MN 55428

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