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Health & Welfare Forms

The following is a list of Health and Welfare plan forms and informational publications that can be requested from the Fund Office.

Some of the plan documents may be available for online viewing in the PDF file format. Adobe's Acrobat Reader® is required.

If you do not have Adobe’s Acrobat Reader® installed on your computer, click here to go to the Adobe website to download and install the most recent version.

If you would like the document mailed to you:

  1. Select the checkbox next to the document’s name (you can select as many different documents as you like).
  2. Once your selections are made, scroll down this page and comlete your personal information.
  3. When ready to send your request, click the Submit button to automatically send the Email request to our Customer Service section.
General Health & Welfare Forms
Document
Description
In-Mail Request
Update your mailing address.
Apply for extended eligibility due to your absence from covered employment because of a disability.
Medical Expense Claim Form
File if you are: submitting a claim with itemized statements or when requested by the Fund Office.
Initially choose, or change your current, hospital-medical plan option.
Initially choose, or change your current, hospital-medical plan option.
Apply for extended benefits coverage for a dependent child over 19 years of age, who is a student at an accredited educational institution.
Designate to whom applicable plan benefits will be distributed after the death of the participating Laborer/Employee.
List and certify applicable stepchildren as eligible for dependent plan benefits.
Provide details on other benefit plans (not affiliated with or provided by Laborers Trust Funds) that may also be covering the participant's spouse and/or dependents. This information is required to coordinate benefit claims payments and processing between the two plans.
Authorize the Trust Funds to electronically send your Vacation benefit checks to your designated financial institution. Faster, convenient and more secure than mailing checks to an address.
Death Notification & Benefit Application Forms
Document
Description
In-Mail Request
Notify the Fund Office of the participant's death (submitted by the surviving spouse or beneficiary).
Notify the Fund Office of the death of a participants spouse or dependent child (submitted by the participant).
Apply for extended death benefits after a participant’s death, if the participant had a certified “total disability” status prior to death.
Enroll eligible beneficiaries of a deceased participant in order to continue applicable benefits.
Dental Benefit Plan Information
Document
Description
In-Mail Request
Pamphlet describing dental benefits for Active Laborers and their dependents.
Pamphlet describing dental benefits for participants in the Laborers Health & Welfare “Special Plan III for Active Employees”.
Pamphlet describing optional dental benefits for Retired Laborers and their dependents.
Pamphlet describing dental benefits for participants in the Laborers Health & Welfare “Special Plan V for Active Employees”.
DeltaPreferred Option (DPO) Optional Dental Plan
Pamphlet describing a new optional dental benefits program for Active, Special Active and Retired Laborers and their dependents.
Bright Now! Dental®
Pamphlet, with application form, describing an optional HMO-type dental benefits program for Active Laborers/Special Active Employees and their dependents.
Application form describing a new optional dental program for Active and Retired Laborers and their dependents.
Pharmacy Benefits Plan Information
Document
Description
In-Mail Request
Prescription Solutions® Mail Service Pharmacy Application Form
Pamphlet, with enrollment form, describing a prescriptions-by-mail service offered as part of the Pharmacy benefit.
Prescription Solutions® Prescription Drug Program Direct Member Reimbursement Form
Complete and return this form when you have purchased a covered, prescribed prescription drug at retail cost and are seeking reimbursement.
Vision Benefits Plan Information
Document
Description
In-Mail Request
Vision Service Plan® Pamphlet for Active Laborers
Pamphlet describing vision benefits for Active Laborers and their dependents.
Vision Service Plan® Pamphlet for “Special Plan III for Active Employees”
Pamphlet describing vision benefits for participants (and their dependents) in the Laborers Health & Welfare “Special Plan III for Active Employees”.
Vision Service Plan® Pamphlet for “Special Plan 311 for Active Employees”
Pamphlet describing vision benefits for participants (and their dependents) in the Laborers Health & Welfare “Special Plan 311 for Active Employees”.
Vision Service Plan® Pamphlet for “Special Plan V for Active Employees”
Pamphlet describing vision benefits for participants (and their dependents) in the Laborers Health & Welfare “Special Plan V for Active Employees”.
Vision Service Plan® Optional Vision Care Pamphlet for Retired Laborers
Pamphlet describing optional vision benefits for Retired Laborers.
Laser VisionCareSM Pamphlet
Pamphlet describing a laser vision correction procedure which is not a Health & Welfare Trust Funds benefit, but is an affiliated service offered at a significant discount to participants enrolled in the Vision Service Plan vision benefits program.

Miscellaneous Benefits & Trust Funds Information

Document
Description
In-Mail Request
Behavioral Health Benefits Pamphlet
Pamphlet describing the Member Assistance Program benefit, sponsored by PacifiCare® Behavioral Health, Inc., which provides free, confidential counseling and referral services to participants and their dependents, for a wide range of behavioral and mental health issues.
Blue Cross® of California's PPO Prudent Buyer Plan® Directory of Health Care Professionals & Institutions
Directory of hospitals, physicians, ambulance services, ambulatory surgery centers, mental health facilities, hospice providers, home health agencies, home infusion therapy providers, laboratories, medical products/service providers, skilled nursing facilities, dialysis centers and ancillary medical providers participating in the Blue Cross® Prudent Buyer Plan PPO network, which is used to provide hospital-medical benefits to participants covered under the Trust Fund's Managed Health Care Plan.
Sheet which compares the major dental plan options.
Sheet which compares the major health and hospital-medical benefits, offered by the Trust Fund's Managed Health Care Plan and any applicable HMO plans, to participants in the Laborers Health & Welfare “Special Plan III for Active Employees”.
Sheet which compares the major health and hospital-medical benefits, offered by the Trust Fund's Managed Health Care Plan and any applicable HMO plans, to participants in the Laborers Health & Welfare “Special Plan V for Active Employees”.
Sheet which compares the major health and hospital-medical benefits, offered by the Trust Fund's Managed Health Care Plan and any applicable HMO plans, to Retired Laborers.
Most recent summary of the annual financial statement for the Laborers Trust Funds for Northern California.
The Benefit Package Quarterly Newsletter
News and information about your benefits, Trust Funds administration and a quarterly "Calendar of Events".
The Training News Quarterly Newsletter
News and information about training and apprentice programs and activities, training courses and class schedules at the Northern California Laborers Training Center.
The Benefit Bulletin Monthly Newsletter
A monthly informational bulletin for our valued participants - assisting you in understanding your benefits.


Personal Information
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Copyright ©2003; Laborers Funds Administrative Office of Northern California, Inc. All rights reserved.
Derechos Reservados Propiedad Literaria ©2003, La Oficina Administrativa de Fondos de los Obreros del Norte de California, Inc.