To complete the Disability Certification, first print your name and Social
Security number in the spaces provided at the top of the form.
Next, take the form to the doctor treating your disability and ask him to
complete Section I. Your doctor must complete this section in full or it will delay your claim.
IMPORTANT:
You must file a Disability Certification with the Fund Office before the end of the eligibility period which follows the
qualifying period for which the disability hour credit is requested or it will be rejected as having been received too late for
acceptance.
If you are also a Participant of the Cement Masons Pension Trust Fund and
you are receiving State Disability Insurance or Workers’ Compensation payments, the Pension Plan may grant you up to 1,040
pension disability hours. If you are receiving disability payments, complete Section II.. You may also be asked
to supply copies of check stubs. (If you are not a Participant of the Pension Plan, skip Section II.).
Read Section III. Your signature authorizes the release of
medical information.
Complete the form by providing the information requested in Section
IV and your signature.
To apply for disability hours credit you can request a Disability
Certification form by contacting the Fund Office, visiting your Local Union or receive the form online here.
