How To Complete the Disability Certification Form

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.