Have you become disabled?

Fill out the Forms

To receive Disability Benefits, fill out the application below and either print and mail it back, or upload the forms and all related documents using our secure Message Center. Everything you need to get started is included in the application, and you must fully complete each section to avoid a delay. It is very important that you provide us with timely notice of your disability, complete the entire benefit application, and send us all appropriate documents such as proof of age, marriage certificate, Social Insurance Award, etc.). 

Please note (Section 4.13 of the Pension Plan) that Disability Benefits will be suspended during Reemployment.

Download the Disability Benefits Application

Download Application 

  • 1

    Disability Benefits Application

    Start by filling out your background information and employment history. Be sure to list all employment, regardless of whether you were a member of the Fund's pension plan. Start with your present or most recent employer. Please add additional pages for employment history if needed.

    You must attach/include copies (not originals) of all appropriate documents including:

    • Copy of your birth certificate (or other proof of age)
    • Copy of your spouse's birth certificate (or other proof of age)
    • Copy of your marriage certificate
    • Copy of your divorce decree
    • Copy of your complete Social Insurance award
    • Copy of your military discharge papers (DD214)

    Be sure to sign and date the application to avoid any delay with your benefit.

  • 2

    IRS Form W-4P Tax Withholding Form

    The IRS does not allow for a specific or flat amount to be withheld. Tax withholding must be based on your marital status and number of allowances plus any additional amounts you wish to have withheld. 

    Please consult your tax professional or see IRS Form W-4P for complete withholding instructions.

    If you want to withhold Federal taxes:

    • Print your name, address, and social security number.
    • Check one of the martial status options and complete the number of allowances on Line 2.
    • You can designate to have an amount withheld in addition to the tax table amount on Line 3.
    • Sign and date the form.

    If you do NOT want to withhold Federal taxes:

    • Print your name, address, and social security number in the space provided.
    • Check the box on Line 1.
    • Sign and date the form.
  • 3

    Benefit Payment Method Form

    This form is required to initiate Disability Benefit payments -- no other form will be accepted. You must keep the Fund informed of any change in your address, regardless of which payment method you chose. We will collect any amount that is overpaid.

    Direct Deposit: Directly depositing your monthly pension check into your bank account is the fastest and most convenient way to receive your pension. Avoid the trip to the bank and sign up today.

    Payment is deposited electronically into your checking or savings account on the first day of each month (unless the first day of the month falls on a weekend or a bank holiday). Because of processing time, your first and/or second payment may be sent by mail.

    If you change banks in the future, you will need a new form.

    Send me my check by mail: Every effort is made to ensure your check is received on the first day of each month. Because of circumstances beyond our control, there is no guaranteed delivery date. In the event a replacement check is necessary, one might not be issued until the 10th day of the month.

    Sign and date the form when finished.

  • 4

    Send Us the Forms

    Be sure to return the entire completed application.

    Message Center
    The fastest way to send in your application is through the secure Message Center. Registered users can log in to upload forms and attach all required documentation. If your form requires a signature, you must print, sign, and then upload the signed page.

    Mail:
    Central States, Southeast and Southwest Areas Pension Fund
    PO Box 5109
    Des Plaines, IL 60017-5109

    Fax:
    847-518-9752

Need Help?

Contact one of our Benefits Specialists for more information on Disability Benefits.

Contact Us