LOCAL 46 IBEW Retirement Annuity Trust
Total and Permanent Disability 401(k) Savings Questionnaire
Physical Address 7525 SE 24th Street Suite 200 Mercer Island, WA 98040 • Mailing Address PO Box 34203 Seattle, WA 98124
Phone (206) 441-4667 or (866) 314-4239 • Fax (206) 695-0984 • Website www.psewtrusts.com
Welfare & Pension Administration Service, Inc
1. Employee's Name (
Print) Social Sec. No.
First Middle Last
2. Employee's Address
3. Date you last worked Date Disability began Phone No.
4. Please state in your own words the nature of your disabilit
5. Have you filed a Claim for Workm
en's Compensation? Yes No If "Yes", State Claim No.
6. Have you filed for Social Security Disability?
Has your claim been approved?
If so, date of approval
Please attach a copy of your Social Security Disability Award
7. Please list name and address of all hospitals to which you were confined and doctors seen in the past year :
NAME AND ADDRESS OF HOSPITALS NAME AND ADDRESS OF DOCTORS
8. Are you engaged in any rehabilitation? If yes, where?
9. Have you worked at any occupation since disability commenced?
a. If yes, please list the name and address of employer and the position you held while employed:
Please Note: When returning this form, you may include copies of any documents (i.e. physician reports, hospital
reports etc.) you feel may be necessary to establish your eligibility for a Disability Pension.
I hereby certify that the foregoing statements, including any accompanying statem
ents, are true, correct and
complete to the best of my knowledge and hereby further authorize my attending physician, practitioner, hospital,
clinic or other medical or medically related facility, insurance company or other organization that has facts
concerning my medical care or physical condition, to disclose, whenever requested to do so by the Welfare and
Pension Administration Service, Inc. any and all such information. A photo static copy of this authorization shall
be considered as effective and valid as the original.
NOTE: Please fill out this questionnaire completely, as all data is pertinent in determining
your eligibility for a Disability Pension award from this Fund. Thank you!
PLEASE HAVE YOUR DOCTOR COMPLETE THE BACK SIDE OF THIS FORM.