Seiuform

SEIU Healthcare 1199NW Multi-Employer Training Fund LifeTek Reimbursement Request Form

Welcome to the SEIU Healthcare 1199NW Multi-Employer Training and Education Fund's LifeTek Reimbursement Form

Submit this quick form in order to notify your Training Fund that you are interested in having a LifeTek course paid for out of your Professional Development benefit. If you do not have enough funds to cover the full course cost you will be personally responsible for the remaining balance to LifeTek.

First Name

Last Name

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Preferred Phone Number

Mobile Phone

Work Phone

Home Phone

May we text you at this number in the future for updates on your benefits?

Preferred Email

Employer

Bargaining Unit

Job Title

Current FTE Range

Course Name You Want?

Date of Course

NOTE: PER DIEM, CONTRACT, AND REGISTERED NURSE EMPLOYEES ARE NOT ELIGIBLE FOR THIS SERVICE

Please Read Regarding Third Party Services:

The Training Fund contracts with vendors for provision of certain services. Based on the Trainings Fund’s contract with each vendor, the Training Fund has agreed that members accessing the service will comply with the policies and terms provided directly by the vendor. By utilizing vendor services though the Training Fund, members agree to these terms. If the vendor discontinues provision of service due to any reason for a member, Training Fund will work with member to explore alternatives that maybe available within current benefits, programs and services.

Amount

Contact Information