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
Administered by
Welfare & Pension Administration Service, Inc
EMPLOYEE'S STATEMENT
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
y
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
Letter
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.
Employee's Signature
Date 20
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.
TOTAL AND PERMANENT DISABILITY PENSION QUESTIONNAIRE
ATTENDING PHYSICIAN’S STATEMENT
Patient's Name Age
Date First Treated Date Last Treated
1. Diagnosis (Please provide ICDA codes if available)
2. Frequency of care? Weekly
Monthly Annual Other
3.
Symptoms are? Progressive Stationary Improving
4. Based on medical evidence, do you believe this Patient is totally and permanently disabled and prevented
from performing duties of his/her occupation? Yes No
Comments::
5. Based on medical evidence, do you believe t
his Patient is totally and permanently disabled and prevented
from performing the duties of any occupation for which he may be qualified by reason of training or
experience?
Yes No
Comments:
6. Dat
e disability commenced?
7. This
disability does or does not result from a self-inflicted injury, habitual use of narcotics or habitual
use of alcoholic beverages. If it does, please explain:
8.
REMARKS:
Date Physician's Name (Print or Type) Physician's Signature
Degree Telephone No.
Street Address City or Town State or Province Zip Code
or
S.S.N. T.I.N.
THIS FORM IS NOT VALID WITHOUT THE PHYSICIAN'S WRITTEN SIGNATURE. A STAMPED
SIGNATURE IS NOT ACCEPTABLE.
S:\Fo
rms\Pension\F33\F33-13-Forms-TotalAndPermanentDisavilityPensionQuestionnaire-06.01.2017.pdf
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