Nineties Brotherhood Fund
Application for Benefits

In order to collect benefits, please print out this page, complete the following and return to fund.

Please Print

Name ____________________________________________________

Address __________________________________________________

City _____________________________________________________

State ____________________ Zip ____________________________

A. Type of claim                     NEW _____________   CONTINUING________

B. Date disability began         _________________________________________

C. Nature of injury or illness. (Describe briefly)  _________________________

     _______________________________________________________________

D. Type of benefit you are now receiving. (Check one)

            1. Workmen’s compensation   ______________

            2. Local 90 Benefit                   ______________

            3. Other – Please describe     ____________________________________

                ___________________________________________________________

            4. None                                    ______________

Please submit proof of claim monthly (Copy benefit check or Doctor’s note)

E. Are you eligible to return to work?          Yes ________     No _________

Signature __________________________________________   Date ________

Please return this form to:

Nineties Brotherhood Fund
P.O. Box 16
Branford, CT 06405