Forms
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Health & Welfare Forms
Add/Delete Dependents Form
Use this form when you need to either add or remove dependents from the BAC3 plan
Health Plan Enrollment Form
This form should be used to enroll in the BAC3 plan once you become eligible for coverage
Retiree Health Application
Retirees should use this form to apply for Retiree Health and Welfare coverage
COBRA Election Form
This form is used to initiate continuous health coverage should you experience a COBRA qualifying event
Request for Continued Coverage for Incapacitated Child
This form is required to be completed every two years if you have a dependent child who has reached the limiting age but continues to have coverage due to a mental or physical handicap.
Change of Beneficiary – Life Insurance
Use this form to change the beneficiary for your Life Insurance benefits
Medical Claim Form
Use this form to obtain reimburement for medical claims
Dental Claim Form
Use this form when you receive covered dental services
Pension Forms
BAC 3 Defined Contribution Pension Application
Use this form to apply for your Defined Contribution Pension benefits if you are a participant in the
BAC Local #3 Defined Contribution Pension Plan
BAC 7 Defined Contribution Pension Application
Use this form to apply for your Defined Contribution Pension benefits if you are a participant in the
San Francisco Bricklayers Local No. 7 Money Purchase Pension Plan
BAC 16 Defined Contribution Pension Application
Use this form to apply for your Defined Contribution Pension benefits if you are a participant in the
Bricklayers and Allied Craftsmen Local No. 16 Defined Contribution Pension Plan
BAC 3 Eligible Rollover Distribution
This is a notice and election form regarding eligible rollover distributions from the
BAC Local #3 Defined Contribution Pension Plan
BAC 7 Eligible Rollover Distribution
This is a notice and election form regarding eligible rollover distributions from the
San Francisco Bricklayers Local No. 7 Money Purchase Pension Plan
BAC 16 Eligible Rollover Distribution
This is a notice and election form regarding eligible rollover distributions from the Bricklayers and
Allied Craftsmen Local No. 16 Defined Contribution Pension Plan
IRS Tax Notice - 2008
This is a notice regarding plan payments and rollovers
Electronic Funds Transfer Form
Use this form if you wish to have your monthly pension payment deposited directly into your checking or savings account.
Tax Withholding Form
Payments from your pension plan are subject to federal and state income tax withholding. This form allows you to declare your tax withholding status
Defined Benefit Pension Application Request
As you near retirement, you will want information about your retirement options. Use this form to request pre-retirement and benefit estimate information
General Use Forms
Change of Information Form
Use this form to change your address or other information you have on file at Allied Administrators