Contact Us: NECA-IBEW Local No. 364 Fringe Benefit Funds  •  6525 Centurion Drive, Lansing, MI 48917-9275  •  Phone - (877) 364-4239  •  Fax - (517) 321-7508


IBEW LOCAL 364 FRINGE BENEFIT FUNDS 

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Health & Welfare Forms


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  • Accidental Injury Questionnaire
  • Affidavit Declaring Marital Status
  • Application for Member Death Benefit
  • Flex Benefit Account Reimbursement Request Form
  • Loss of Time and Attending Physician's Statements
  • Loss of Time Direct Deposit Authorization Agreement
  • Participant Data and Beneficiary Form
  • Retiree Direct Debit Authorization Agreement
  • Retiree SUB Fund Self-Payment Election
  • Self-Payment Minimum Coverage Election
  • Spousal Other Insurance Reimbursement Form
  • Yearly coordination of Benefits and Dependent Status

If you have questions, comments, or concerns regarding this web site, please direct them to the following address below:

NECA-IBEW Local No. 364 Fringe Benefit Funds
6525 Centurion Drive, Lansing, MI 48917-9275
Phone: (877) 364-4239  •  Fax: (517) 321-7508

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IBEW    NECA