Reciprocity Request Form

This reciprocity request form is for Local 11 Members that have worked outside their area and need to confirm their hours are counted towards their benefits. By filling out this form and submitting it to OPCMIA Local 11 with your information, you are giving Local 11 the permission to manually enter the required information into the paper form and submit it to the fund office in your place. You must fill out all fields, check the “legal statement” box below, and fill in the security check. Thank you.

Reciprocity Request Form

Member Information

Enter your information in the fields below. All fields must be completed.

Your Name(Required)

First Last

Last 4 Digits of SSN

Registration Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

City/State

TRANSFERRING FUND (Where you worked)

Date

TRANSFERRING FUND (Date you worked)

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)