International Masonry Training and Education Foundation

Maternity Disability Benefit

The International Masonry Training and Education Foundation’s (IMTEF’s) paid maternity disability benefit supports pregnant women craftworkers and new mothers represented by the International Union of Bricklayers and Allied Craftworkers (BAC). 

The plan provides $600 a week for up to 6 weeks immediately following a traditional delivery, or up to 8 weeks following a c-section.

The plan also provides a short-term disability benefit of $600 per week if you are certified by your physician to be unable to work due to a pregnancy-related physical illness or condition, but not sooner than the 4th month of pregnancy.  

Your total combined benefit for pre- and post-delivery periods is capped at twenty-six (26) weeks. 

Physician’s Alert: Safety & Health

Eligibility

To be eligible for the benefit, you must: 

  • Be a BAC craftworkers in the U.S. 
  • Have performed at least 1,000 hours of “Covered Employment” for which required contributions have been paid within the 12 months immediately preceding the onset of your pregnancy-related disability or the birth of your child(ren).  

How to Apply

To apply, complete and submit the secure disability claim form below, or download the printable PDF and submit by mail, email, or fax using the contact information on the form.

Questions

For questions, contact the Amalgamated Employee Benefits Administrators toll free at 1-866-975-4091 or review our FAQ for BAC Craftworkers.

For complete details on the plan, see the Summary Plan Description.

DISABILITY CLAIM FORM
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AUTHORIZATION HIPAA RELEASE FORM
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W4 FORM
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DISABILITY CLAIM FORM

CLAIMANT INFORMATION

Gender

CLAIMANT DATES OF DISABILITY AND WORK STATUS

Have you been continuously totally disabled?

If 'No,' have you been continuously partially disabled?

I worked on that day

Have you since worked for wages or profit?

If 'Yes,' give dates: to

Have you returned to work?

If 'Yes,' indicate date:

FOR PRE-DELIVERY PREGNANCY DISABILITY, ANSWER THE FOLLOWING QUESTIONS
ABOUT THE CONDITION(S) CAUSING YOUR DISABILITY

Prior to this disability claim, did you receive a diagnosis, medical care, including hospitalization, treatment, surgery, or advice and recommendation for the condition on this claim?

If 'Yes,' please explain.

FOR POST-DELIVERY (MATERNITY) DISABILITY, ANSWER THE FOLLOWING QUESTIONS

What is your expected delivery date?

Have you delivered?

If 'Yes,' date of delivery

Type of Delivery

Requested End Date of Maternity Disability:

a) Were there any complications causing you to stop work prior to your expected delivery date?

b) Were there any post-delivery complications?

c) If 'Yes' to either question, please explain.

INFORMATION ABOUT TREATING PROVIDER(S)

Provide the following information on all your medical treatment providers (physician, hospital, therapists, etc.) for this disability, including any referring physician and specialist. If needed, attach a separate sheet of paper.

Add More Provider(s)
WORK INFORMATION

What was your occupation when disability commenced, and what were the usual duties of your occupation?

Which of the above job duties are you unable to perform?

FRAUD WARNING

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

For residents in the following states, please see the last page of this form. Alabama, Alaska, Arizona, California, Colorado, Delaware, District of Columbia, Florida, Idaho, Indiana, Kentucky, Maine, Maryland, Minnesota, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Virginia and Washington.

CLAIMANT CERTIFICATION

I HEREBY CLAIM DISABILITY AND CERTIFY THAT FOR THE PERIOD COVERED BY THE CLAIM I WAS DISABLED; AND THAT THE FOREGOING STATEMENTS, INCLUDING ANY ACCOMPANYING STATEMENTS, ARE TO THE BEST OF MY KNOWLEDGE TRUE AND COMPLETE.

IF I RECEIVE A DISABILITY BENEFIT GREATER THAN THAT WHICH I SHOULD HAVE BEEN PAID, I UNDERSTAND THAT AMALGAMATED EMPLOYEE BENEFITS ADMINISTRATORS HAS THE RIGHT TO RECOVER SUCH OVERPAYMENTS FROM ME, INCLUDING THE RIGHTS TO REDUCE OR ADJUST FUTURE BENEFITS, IF ANY.

AUTHORIZATION TO RELEASE INFORMATION

Read, sign and date the Authorization for Release of Health Care Information Pursuant to HIPAA (below), and provide a copy to your treating physician. Submit a copy to Amalgamated Employee Benefits Administrators along with your claim.

HIPAA AUTHORIZATION RELEASE FORM

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. In accordance with the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 290dd-2 and its implementing regulations at 42 C.F.R. Part 2, I understand the following:

I hereby give permission and authorize any health care provider including, but not limited to, any health care professional, hospital, clinic, laboratory, pharmacy or other medically related facility or service; health plan; rehabilitation professional; vocational evaluator; and employer that has information about my health, employment history, or other insurance claims and benefits to disclose any and all of this information to persons who administer and evaluate claims for Amalgamated Employee Benefits Administrators (AEBA), including Amalgamated Medical Care Management (AMCM), an affiliate of Amalgamated Employee Benefits Administrators.

Genetic Information: NOTE TO ALL HEALTH CARE PROVIDERS: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information, as defined by GINA, when responding to this request for medical information.

This authorization may include disclosure of information relating to: Alcohol and Drug abuse, Mental Health Treatment, except psychotherapy notes, and Confidential HIV Related Information, only if I place my initials on the appropriate item below. In the event the health information described below includes any of these types of information, and I initial the line on the box in the item below, I specifically authorize release of such information to Amalgamated Employee Benefits Administrators (AEBA), including Amalgamated Medical Care Management (AMCM), an affiliate of Amalgamated Employee Benefits Administrators.

IMPORTANT - Please complete the check boxes below even if the categories should not necessarily apply to the patient's medical records.

    want information about Mental Health released

    want information about HIV Tests & Related Information released

    want information about Alcohol and/or Substance Abuse released

If I am authorizing the release of HIV-related, alcohol, or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV related information without authorization.

I understand that any information AEBA or AMCM obtains pursuant to this authorization will be used for evaluating and administering my claim(s) for disability benefits. I further understand that authorized recipients to my medical information may, in certain instances, have the right to redisclose my medical documentation without the need to obtain additional written consent from me. I understand that such redisclosures may no longer be protected by federal or state law.

I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. However, if I do not authorize release of my medical information, this may result in Amalgamated Employee Benefits Administrators not being able to process my claim.

I have the right to revoke this Authorization at any time by providing written notice of revocation to Amalgamated Employee Benefits Administrators. I am aware that my revocation will not be effective until received by Amalgamated Employee Benefits Administrators and will not be effective regarding the uses and/or disclosures of my 'Information' that has been made prior to receipt of my revocation. This authorization is valid for one year from the date below or the duration of my claim, whichever is shorter. A photographic or electronic copy of this authorization is as valid as the original. I understand I am entitled to receive a copy of this authorization.

This authorization does not authorize my medical provider to discuss my health information or medical case with anyone other than AEBA or AMCM.

If other than patient: I signed on behalf of the patient as .

If Power of Attorney Designee, Guardian, Conservator, please attach a copy of document granting authority.

Maternity Plan SPD Maternity Leave FAQ W4 Form

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.

FRAUD WARNINGS FOR CLAIM FORMS

Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines and confinement in prison, or any combination thereof.

Maine, Tennessee and Washington Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Delaware, Idaho and Indiana Residents: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

Alaska Residents: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under the law.

Arizona Residents: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

California Residents: For your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Department of Regulatory Agencies - Division of Insurance.

District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.

Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Hampshire Residents: Any person who, with a purpose to injure or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. §638.20.

New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Ohio Residents: Any person who, with intent to defraud or knowingly is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto that the insurer relied upon is subject to a denial and/or reduction in insurance benefits and may be subject to any civil penalties available.

Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Virginia Residents: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or fraudulent statement may have violated state law.