INQUIRY REGARDING PENSION CREDITS - UFCW and …

1 INQUIRY REGARDING PENSION CREDITSTO: ufcw Employers Benefit FundsPlease check:1000 Burnett Ave. Ste. 110 Concord, CA 94520-2000 Box 4102 Concord, CA 94524-4102 Food/Meat Industry EmploymentPhone # (800) 552-2400 Drug Store EmploymentSpecialty Stores EmploymentEMPLOYEE to complete / Print or TypeNAMESEXUFCW Union #MaleFemaleSTREET ADDRESSSOC. SEC. NUMBERDATE OF BIRTHCITYSTATEZIPDATE FIRST EMPLOYED IN INDUSTRYTELEPHONE (DAYS)DATE LAST EMPLOYED IF NOT CURRENTANY OTHER SURNAME , maidenI AM PLANNING TO RETIRE SOONYesNoARE YOU WORKING AT PRESENT IN CALIFORNIA UNDER A ufcw CONTRACT?IF NO, PLEASE ADVISE YOUR CURRENT WORK STATUSYesNoComplete your employment history below beginning with the store or company where you are now employed and list all jobs back to thefirst one, showing the type of work (Clerk, Meatcutter,Pharmacist, Manager, etc.)DATES OF EMPLOYMENTFromToMonthYearMonthYearPresen tNAME OF STORE/COMPANYCITY12345678 PresentEmployerFromToMonthYearMonthYearD ATES OF BREAKSIN EMPLOYMENTREASONS FOR BREAK IN EMPLOYMENTM ilitary Service(ATTACH DD-214 s)Illness or injury (PROVIDE DOCTOR S NAME AND COMPLETE MAILING ADDRESS ON BACK OF FORM)Exempt Employment (EMPLOYER/POSITION/LOCATION) ufcw employment outside Northern California(EMPLOYER AND LOCATION)Worked in other industry or trade(EMPLOYER AND TYPE OF WORK)Self-Employment(TYPE OF STORE/INDUSTRY/LOCATION)Other Causes(STATE BRIEFLY AND GIVE DATES):I hereby certify that the foregoing statements, including any accompanying statements, are to the best of my knowledge and belief, true,correct and complete.

2 I hereby authorize any physician, any hospital or insurance company to furnish and disclose all known factsconcerning my history. A copy or photocopy of this authorization shall be as valid as the _____ Date_____THIS IS NOT AN APPLICATION FOR RETIREMENT you wish to apply for PENSION Benefits, contact your Union Local or the Fund complete the section below for all periods of your work history during which you were not ina union position in the :Admin/Templates and Forms/ PENSION Credit InquiryFOR PERIODS OF DISABILITY PLEASE PROVIDE COMPLETEPHYSICIAN S NAME, ADDRESS, AND PHONE NUMBER BELOWP hysician s Name:_____ thru _____Address:City/St/Zip:Telephone Number:Did you receive Worker s Compensation?State Disability?If yes to either question, and you were employed in the food or meat industry, please attach copies of benefit payments. (If you do not have all copies, please contact State Disability for Form DIS0306 or your Workers Compensation carrier to obtain a print-out of their payment records.)

3 _____ thru _____Did you receive Worker s Compensation?State Disability?If yes to either question, and you were employed in the food or meat industry, please attach copies of benefit thru _____Did you receive Worker s Compensation?State Disability?If yes to either question, and you were employed in the food or meat industry, please please attach copies of benefit DisabledPeriod DisabledPeriod DisabledYesNoYesNoYesNoYesNoYesNoYesNoPh ysician s Name:Address:City/St/Zip:Telephone Number:Physician s Name:Address:City/St/Zip:Telephone Number:mm/dd/yymm/dd/yymm/dd/yymm/dd/yym m/dd/yymm/dd/yyH:Admin/Templates and Forms/ PENSION Credit INQUIRY