NATIONAL ELEVATOR INDUSTRY
HEALTH BENEFIT PLAN
SPECIAL 14-DAY WEEKLY INCOME BENEFIT FORM
Instructions: Complete “PLAN MEMBER” Section Only.
(610) 557-4556 (fax)
National Elevator Industry Health Benefit Plan
PO Box 476
Newtown Square, PA 19073-0476
TO BE COMPLETED BY MEMBER
Name ____________________________________________________ Last Four of Social Security No. ____________
Street __________________________________________________________ Birth Date ______________ Local Union No. __________
City _______________________________________ State __________ Zip Code ___________ Phone ______________________
Employer Name ________________________________________________________ Last day worked ______________________
Employer Contact ____________________________________________________ Employer Phone Number _______________________
Check the appropriate box:
My Employer directed me to Self-Quarantine on account of Coronavirus Disease 2019 (COVID-19), OR
My Employer did not direct me to Self-Quarantine, but I believe I should Self-Quarantine because I have been exposed to COVID-19 or
have symptoms of COVID-19 (subjective or measured fever, cough, or difficulty breathing).
Direct Deposit Election □ Yes □ No CHECKING ACCOUNT DEPOSITS ONLY
If direct deposit is elected, A BLANK PERSONAL CHECK (MARKED “VOID”) MUST ACCOMPANY THIS FORM.
Account Number ________________________________________ Banking Routing Number ___________________________________
Bank Name _______________________________________________ Street _________________________________________________
City _______________________________________ State _____________ Zip Code ____________ Phone ______________________
I request voluntary Federal Withholding □ Yes □ No If “Yes”, indicate amount to be withheld from weekly benefit. $ _________________
I am the payee under the above Social Security Number and I hereby request that until further notice from me is filed with the Claims
Administrator, all payments be directly deposited in my account at the Bank designated above. I authorize the Bank designated to debit my
account and to refund any overpayments to the National Elevator Industry Health Benefit Plan.
I agree to reimburse the Health Benefit Plan to the extent of any overpayment which is in excess of the amounts payable under provisions of the
ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING
INFORMATION, WITH INTENT TO INJURE, DEFRAUD OR DECEIVE, MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW
AND SUBJECT TO LOSS OF HEALTH BENEFIT PLAN COVERAGE.
I certify that the statements hereon are complete and accurate to the best of my knowledge. A photocopy of this authorization shall be
considered as effective and valid as the original.
Signature of Plan Member _______________________________________________________ Date ________________________
IMPORTANT: By submitting this form, you are ONLY applying for Special 14-Day Weekly Income Benefits the Plan provides eligible
Active Members who Self-Quarantine on account of COVID-19. If you wish to apply for Weekly Income Benefits on account of Illness or
Injury you must submit the applicable Weekly Income Claim Form which must also be filled out by your Physician and Employer.
These forms are available online at www.neibenefits.org/members/health-plan/
TO BE COMPLETED BY THE BENEFITS OFFICE
Employer Name ________________________________________________________ EIN _____________________________________
Employee Self-Quarantine Confirmed
□ YES □ NO
If “Yes” Date _____________________________
If “No” explanation: _________________________________________________________________________________________________
Reviewed by __________________________________ Date _______________________
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