United Retired Pilots Benefit Protection Association

If you are a retired United pilot or spouse,
please fill in the requested information below.
Privacy Note: Information submitted here will be sent to Jim Krasno by E-Mail. Jim is a retired United Captain and a member of the Board of Directors of the United Retired Pilots Benefit Protection Association (URPBPA). The information will be used only for the purpose of protecting our pensions and benefits. It will not be sold or given to any other group. Some of the information requested is needed to understand the scope of the pension and benefit risks that apply to each retired pilot.

Completing this form allows us to keep in touch with you via e-mail or snail mail. Retired pilots, spouses, and others receiving UAL pilot retirement or medical benefits are elgible for membership. If you wish to join URPBPA, please check the "Membership: Please Send Me a URPBPA Membership Application Form" box in the form below. URPBPA will send you a membership application form and a table to calculate the amount due to become a member. When we receive the completed form and fee your membership will be processed.

First Name:
Last Name:
Salutation: IE: Capt, Mr, Ms, etc.
E-mail Address:
Telephone Number:
Street Address:
City:
State:
Zip+4 or Postal Code:
Birth Date: mm/dd/yyyy
Date Hired: mm/dd/yyyy
Retirement Date: mm/dd/yyyy
File Number:
Membership:	I am a URPBPA Member Please Send Me a URPBPA Membership Application Form I am Just Visiting this Web Site
Status:	Retired Pilot Spouse of Retired Pilot Medically Retired Pilot Spouse of Medically Retired Pilot Active Pilot Spouse of Active Pilot
Pilot Medical Coverage Information:	Pilot Before Medicare Traditional Pilot Before Medicare HMO Pilot After Medicare "Supplemental" Pilot After Medicare "Comprehensive" Pilot UAL HMO Pilot Other Medical Coverage
Spouse Medical Coverage Information:	Spouse Before Medicare Traditional Spouse Before Medicare HMO Spouse After Medicare "Supplemental" Spouse After Medicare "Comprehensive" Spouse UAL HMO Spouse Other Medical Coverage
Other Information:	I Retired under Contract 2000 I Retired under Contract 2003 before July 1, 2003 I Retired under Contract 2003 after June 30, 2003 I Get a Non-Qualified Retirement Check (NONQUAL) I want to Volunteer to Help
Comments:

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For Information Contact Jim Krasno