HAWAII TEAMSTERS TRUST FUNDS 560 N. Nimitz Highway, Suite 209, Hnlulu, Hawaii 96817 Phne (808) 523-0199 Tll-Free 1 (866) 772-8989 Fax (808) 537-1074 Hawaii Truckers Teamsters Health & Teamsters Legal Teamsters Training Teamsters Unin Welfare Trust Fund Services Plan and Opprtunity Pensin Plan Prgram MONTH XX, 20XX NAME ST. ADDRESS / P.O. BOX CITY, ST ZIP CODE RE: HAWAII TRUCKERS-TEAMSTERS UNION PENSION PLAN PENSION APPLICATION Dear Member: Pursuant t yur request, we have enclsed an Applicatin fr Retirement Benefits. Please cmplete the Applicatin and return it, with cpies f the necessary dcuments, t the Trust Fund Office in the enclsed self-addressed return envelpe. Please be aware that it may take several mnths t prcess yur pensin applicatin. Upn cmpletin f yur Retirement Benefit estimates, we will send yu the Electin frm which yu will then elect the type f benefit frm yu wuld like t receive. If yu have any questins regarding yur retirement, please feel free t cntact the Trust Fund Office, Pensin Department. Sincerely, Enclsures cc: File Pensin Department
HAWAII TRUCKERS TEAMSTERS UNION PENSION PLAN APPLICATION FOR BENEFITS Part I. RETIREE INFORMATION Full Name (Last) (First) (Middle) Date f Birth (mm/dd/yyyy) Previus Name, If Any: (Last) (First) (Middle) Gender Female Male Mailing Address (Street) (City) (State) (Zip Cde) (Phne N.) Martial Status Married Divrced (Submit Divrce Decree) U.S. Citizen Yes Single Widwed (Submit Death Certificate) N *IF YOU HAVE EVER BEEN DIVORCED, SUBMIT A FILED COPY OF THE DIVORCE DECREE. **IF THERE IS A DOMESTIC RELATIONS ORDER IN EFFECT AWARDING A PORTION OF YOUR POSSIBLE PENSION BENEFITS TO YOUR FORMER SPOUSE, SUBMIT A FILED COPY OF THE ORDER. Scial Security Number Trucking Cmpany Emplyer Date f Hire Last Day Wrked Term Date Psitin Held *IF YOU HAVE ANY BREAKS IN SERVICE DUE TO MILITARYSERVICE, BE SURE TO FURNISH DISCHARGE PAPERS SHOWING BOTH INDUCTION AND DISCHARGE DATES.ALSO, IF APPLICABLE, INDICATE EMPLOYMENT HISTORY WITH U.P.S. MAINLAND U.S.A. Part II. SPOUSE INFORMATION Full Name (Last) (First) (Middle) Date f Birth (mm/dd/yyyy) Previus Name, If Any: (Last) (First) (Middle) Scial Security Number Date f Marriage (mm/dd/yyyy) *SPOUSE MUST SUBMIT BIRTH CERTIFICATE & MARRIAGE CERTIFICATE. SUBMIT PROOF OF NAME CHANGE IF ANY. Part III. ONE-TIME BENEFICIARY DESIGNATION Full Name (Last) (First) (Middle) Date f Birth (mm/dd/yyyy) Scial Security Number Relatinship t Retiree Gender Female Male Mailing Address (Street) (City) (State) (Zip Cde) (Phne N.) I hereby request retirement under the Hawaii Truckers Teamsters Unin Pensin Plan. I will immediately ntify the Hawaii Truckers Teamsters Unin Pensin Plan if I return t emplyment in the same industry in the same trade r craft in Hawaii. I understand that my mnthly pensin payments will be suspended fr any calendar mnth f such emplyment in which I wrked 40 r mre hurs. Signature (Required) Date Signed
BENEFIT OPTIONS Yur benefits will be paid t yu in the nrmal frm, at such times as prvided fr yu in the Plan, unless yu elect t waive this frm f benefit (with yur spuse s cnsent if yu are married). IF YOU ARE NOT MARRIED, the nrmal frm is a Single Life Annuity Benefit which prvides yu with the mnthly payments fr yur life. The benefit payments will cease with the benefit payment fr the mnth f yur death. IF YOU ARE MARRIED, the nrmal frm is the an Autmatic Jint and Last Survivr Annuity Benefit fr Married Participants which prvides yu with a reduced mnthly payment fr yur life, and, upn yur death, a mnthly payment fr yur spuse s life equal t 50% f the mnthly payment yu received prir t yur death. If yur spuse dies befre yu, n payments will be made after yur death. The amunt f reductin is determined based n the age difference between yu and yur spuse. Yu may elect nt t receive yur benefits in the nrmal frm and instead chse t receive yur benefits in ne f the ptinal distributin frms listed belw. Yur spuse s cnsent is needed if yu elect nt t receive yur benefits in the nrmal frm. Yur ptinal frms are as fllws: (1) Single Life Annuity Benefit. Under this ptinal frm, yu are prvided with a mnthly pensin fr yur life. The benefits payments will cease with the benefit payment fr the mnth f yur death. (2) Qualified Optinal Jint & Survivr Pensin (fr married Participants). Under this ptinal frm, yu are prvided with a *reduced mnthly pensin fr yur life. When yu die, mnthly payments will be prvided fr yur spuse s life equal t 75% f the mnthly pensin yu received prir t yur death. If yur spuse dies befre yu, payments will cease with the payment fr the mnth in which yu die. *The amunt f the reductin is based n the age difference between yu and yur spuse. (3) Cntingent Annuity Optin Benefit. Under this ptinal frm, yu are prvided with a *reduced mnthly pensin fr yur life. When yu die, mnthly payments will be prvided t yur designated beneficiary, if living. He r she will receive a mnthly pensin fr his r her lifetime equal t 50%, 66 2/3%, r 100%, f the pensin amunt that yu had been receiving prir t yur death. Yur designated beneficiary may be limited by the Trustees t certain classes f persns but, yu chse the persn wh is t receive the survivr benefit. Yu als chse the percentage f yur mnthly pensin t be paid t yur designated beneficiary (restrictins may apply if the beneficiary is nt yur spuse). If yur designated beneficiary pre-deceases yu, the pensin payments will cease with the pensin payment fr the mnth in which yu die. If prir t yu actual retirement, yu shuld die r yur designated beneficiary pre-deceases yu, the electin f the ptin shall becme null and vid and f n effect. *The amunt f the reductin is based n the age difference between yu and yur spuse. (4) Scial Security Optin Benefit. Under this ptinal frm, yu are prvided with an actuarially adjusted benefit which will prvide a greater amunt during the perid befre yu becme eligible fr Scial Security benefits (age 62 in mst cases) and a reduced amunt thereafter s that, as nearly as pssible, yu will receive a level mnthly incme fr life (taking int accunt yur estimated Scial Security benefits). The benefit payments will cease with the benefit payment fr the mnth f yur death.
HAWAII TRUCKERS TEAMSTERS UNON PENSION PLAN TO THE BOARD OF TRUSTEES: This is t cnfirm that I, (PRINT NAME) Scial Security Number: (CHECK ONE) WISH TO RETIRE THE FIRST DAY OF THE MONTH FOLLOWING THE DATE OF THIS APPLICATION WISH TO RETIRE THE FIRST DAY OF THE MONTH IMMEDIATELY FOLLOWING MY ATTAINMENT OF NORMAL RETIREMENT AGE WISH TO RETIRE ON THE FIRST DAY OF THE MONTH SIX MONTHS PRIOR TO THE DATE OF THIS APPLICATION THE FIRST DAY OF THE (MONTH) (YEAR) AT AGE DO NOT WISH TO SET A RETIREMENT DATE AT THIS TIME (ATTAINMENT OF AGE 70 ½) PENSION BENEFIT APPLIED FOR: (CHECK ONE) NORMAL (AGE 62) EARLY (AGE 55 AGE 61-11) POSTPONED (AGE 62-01 AND BEYOND) *DISABILITY *ATTAINMENT OF AGE 70½ *PLEASE CONTACT THE ADMINSTRATIVE OFFICE TO VERIFY YOUR ELIGIBLITY INDICATE BELOW THE BENEFIT OPTIONS FOR WHICH YOU WOULD LIKE TO HAVE ESTIMATES DONE: 1. [ ] SINGLE LIFE ANNUITY BENEFIT 2. [ ] QUALIFIED OPTIONAL JOINT & SURVIVOR PENSION (fr married Participants) 3. [ ] CONTINGENT ANNUITY OPTION BENEFIT (Prvide Birth Certificate & Marriage Certificate if applicable) Name f Cntingent Beneficiary: Date f Birth: Sc. Sec. N.: Relatinship: Address: 4. [ ] SOCIAL SECURITY OPTION BENEFIT (Prvide Earnings Statement frm Scial Security Administratin) Signature Date
LIST OF ACCEPTABLE DOCUMENTS PROOF OF AGE MUST BE FURNISHED BEFORE RETIREMENT BY ALL APPLICANTS THE SAME IDENTIFICATION RULES APPLY TO YOUR SPOUSE AND YOUR CONTINGENT BENEFICIARY. YOU WILL ALSO NEED TO PROVIDE A COPY OF YOUR MARRIAGE CERTIFICATE. ITEMS ARE LISTED BY ORDER OF PREFERENCE. IF YOU ARE UNABLE TO SUPPLY A DOCUMENT SHOWN UNDER GROUP I, SUBMIT AT LEAST TWO OF THE OTHER DOCUMENTS SHOWN UNDER GROUP II. (THE FUND MAY REQUEST ADDITIONAL PROOF IF A CONFLICT EXISTS WITH OTHER INFORMATION OBTAINED.) ALL DOCUMENTS WILL BE RETURNED TO YOU AFTER RECORDING BY THE FUND OFFICE. I SUBMIT THE FOLLOWING PROOF OF AGE: GROUP I (ONE PROOF REQUIRED) BIRTH CERTIFICATE BAPTISMAL CERTIFICATE, SIGNED BY CHURCH OFFICIAL CERTIFIED BIRTH REGISTRATION CERTIFICATION OF RECORD OF AGE BY THE U.S. CENSUS BUREAU HOSPITAL BIRTH RECORD, SIGNED BY THE HOSPITAL ADMINISTRATION FOREIGN CHURCH OR GOVERNMENT RECORD SIGNED STATEMENT OF PHYSICIAN OR MIDWIFE IN ATTENDANCE NATURALIZATION RECORD IMMIGRATION RECORD GROUP II (TWO PROOFS REQUIRED) MILITARY RECORD PASSPORT CERTIFIED SCHOOL RECORD CERTIFIED VACCINATION RECORD INSURANCE POLICY SHOWING DATE OF BIRTH OR AGE CERTIFIED MARRIAGE RECORD, SHOWING DATE OF BIRTH OR AGE OTHER RECORDS SUCH AS SIGNED STATEMENTS FROM PERSONS WHO HAVE KNOWLEDGE OF THE DATE OF BIRTH.
RETIREMENT DECLARATION (Ntice f Cntinued Eligibility fr Retirement Benefits and Suspensin f Benefits upn Reemplyment) Retirees Name: SSN: The Hawaii Truckers - Teamsters Unin Pensin Plan (the Plan ) prvides that yu may retire at any time after attaining Nrmal Retirement Age and receive full Nrmal Retirement Benefits under the Plan, starting immediately upn retirement. Retirement is permitted under the Plan befre Nrmal Retirement Age if yu have met the minimum age and service requirements, with Early Retirement Benefits cmmencing befre Nrmal Retirement Age n a reduced basis. Having submitted an applicatin fr retirement benefits under the Plan, yu are acknwledging that yu will be bund by the rules and regulatins f the Plan and that yu understand the Plans reemplyment and suspensin f benefits prvisins as fllws: (a) Suspensin f Benefits. A retired Emplyee wh returns t emplyment in the same industry in the same trade r craft in Hawaii shall have his mnthly pensin payments suspended fr any calendar mnth f such emplyment in which he wrked frty (40) r mre hurs. Fr purpses f this subsectin: (1) The same industry means the business activity f the type engaged in by any Emplyer maintaining the Plan, including self-emplyment. (2) The same trade r craft means an ccupatin in which the Emplyee was emplyed at any time under the Plan, r supervisry activities relating t skill r skills utilized in such ccupatin. (b) (c) Resumptin f Payments. If pensin payments are suspended, payments shall resume n later than the first day f the third calendar mnth after the calendar mnth in which the Retiree ceases t be emplyed, prvided that the Retiree has ntified the Trustees that he has ceased such emplyment. The initial payment when resumed will include the payment scheduled t ccur in the calendar mnth when payments resume and any amunts withheld during the perid between the cessatin f emplyment and the resumptin f payment, less any amunts which are subject t ffset. Offset Rules. The Plan will ffset frm benefit payments any verpayments made by the Plan t a Retiree. The ffset shall be limited t ne hundred percent (100%) f the amunt due t the Pensiner fr the first payment upn resumptin f benefits and twenty five (25%) percent f the mnthly benefit amunt thereafter until all verpayments are fully recvered.
(d) Verificatin. A Retiree, as a cnditin t receiving pensin payments, must ntify the Trustees f any emplyment after his retirement and must prvide such reasnable infrmatin as the Trustees may request fr the purpse f verifying such emplyment. In additin at least nce each year, n a frm apprved by the Trustees, a Retiree must certify r prvide factual infrmatin sufficient t establish that he is nt and has nt been emplyed at wrk which wuld cause a suspensin f pensin payments, as described in (a) abve. Payments therwise due may be withheld until such requested certificatin r infrmatin is prvided. (e) Status Determinatin. The Retiree may request, in writing, and the Trustees in a reasnable amunt f time, will render a determinatin f whether specific cntemplated emplyment will require suspending benefits. Requests fr status determinatin may be cnsidered in accrdance with the claims prcedure described belw. (f) (g) Ntificatin. The Trustees shall send a ntice by certified mail t each suspended Retiree during the first calendar mnth in which the Plan withhlds pensin payments. The ntice shall describe the suspensin f pensin payments and the prcedures that may be used t appeal such a suspensin. Benefit Upn Subsequent Retirement. A Retiree wh returns t emplyment and has his pensin payments suspended shall, upn his subsequent retirement, be entitled t receive an increased pensin based upn his riginal pensin amunt(s) plus any additinal pensin amunt accrued while reemplyed. When pensin payments resume, after subsequent retirement, there are n make-up payments r ther adjustments t the riginal pensin amunt(s) t reflect the fact that the Retiree did nt receive pensin benefits during the perid f resumed emplyment when he culd have remained retired and cntinued t receive benefits. In ther wrds, resumed emplyment is an alternative t pensin benefits fr the perid f the resumed emplyment and nt just a deferral f the benefits that wuld have been paid during that time, had the Retiree chsen nt t return t wrk. If yur benefits are suspended and yu wish t have yur benefit suspensin reviewed, the Plans claim review prcedures are as fllws: Claim Review Prcedure When a claim is denied, the claimant r his duly authrized representative may file an Applicatin fr Review, hereinafter called Applicatin, as fllws: (a) (b) (c) (d) The Applicatin shall be in writing; The Applicatin shuld be submitted within sixty (60) days after receipt f the Ntice f Denial; it may be rejected if it is filed after then unless it is filed within a perid f time which is reasnable under the circumstances; The claimant r his duly authrized representative may review pertinent dcuments; and The claimant r his duly authrized representative may submit issues and cmments in writing.
Upn receipt f the Applicatin, the Trustees shall make a full and fair review f the denial f the claim. Its decisin shall be made within sixty (60) days after the Plans receipt f the Applicatin, unless special circumstances require an extensin f time fr prcessing the Applicatin; in which case the decisin shall be rendered as sn as pssible, but nt later than ne hundred twenty (120) days after receipt f the Applicatin. It shall be up t the Trustees t decide whether r nt a hearing wuld be useful; if a hearing is t be held, the claimant and his duly authrized representative shall receive at least tw weeks ntice f the time and place f the hearing (unless it is agreed in writing t a shrter ntice). The claimant and his duly authrized representative may appear at such hearing. The decisin n review shall be in writing and shall include specific reasns fr the decisin, written in a manner calculated t be understd by the claimant. It shall als include specific references t the pertinent Plan prvisins n which the decisin is based. The Plans suspensin f benefits prvisins and this ntificatin are bth in cmpliance with regulatins published by the U.S. Department f Labr at 29 Cde f Federal Regulatins sectin 2530.203-3. If yu have any questins regarding the abve infrmatin, please cntact the Trust Fund Office lcated at 560 Nrth Nimitz Highway, Suite 209, Hnlulu, Hawaii 96817, telephne number 808-523- 0199 during the hurs f 8:00 A.M. t 4:30 P.M., Mnday thrugh Friday. The Fllwing Sectin Must Be Cmpleted By The Retiring Emplyee (fr assistance with respect t (4) and (5) belw, please refer t the attached Emplyer/Business Activity listing): By my signature belw, I hereby affirm the fllwing: (1) I am applying fr benefits frm the Hawaii Truckers -Teamsters Unin Pensin Plan (the Plan ). (2) I have read and understand the Plans suspensin f benefits prvisin as explained abve. (3) I am nt currently emplyed in any capacity, including self-emplyment r supervisry activities, in the type f wrk fr which I was emplyed at any time under the Plan. (4) I am nt currently emplyed by any emplyer whse business activity is the same type f activity engaged in by any Emplyer currently maintaining the Plan. (5) I am nt currently emplyed by any Emplyer wh is a party t a written Labr Agreement with the Hawaii Teamsters and Allied Wrkers, Lcal 996 which cvers emplyees participating in the Plan. I hereby certify that my last emplyer was (Name f emplyer) and that my last day f emplyment was n. (Date) (Retirees Signature) (Date)
Emplyers Currently Maintaining the Hawaii Truckers-Teamsters Unin Pensin Plan Hawaii Teamsters and Allied Wrkers, Lcal 996 (Unin) Hawaii Transfer Cmpany, Ltd. Martin Transprtatin Services Mercantile Trucking Service, Ltd. Unicld Crpratin United Parcel Service (UPS) Yellw Transprtatin (YRC, Inc.) Business Activities Engaged in by Emplyers Currently Maintaining the Plan Cnslidated parcel delivery Cntainer hauling/lading and unlading f strage cntainers Cld strage space rental Distributin and warehusing Freight distributin and warehusing Freight trucking, pick-up and delivery services (including tractrs, flatbeds and vans) Labr unin/labr rganizatin Transprtatin and public warehusing (excluding self-strage units)