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
VisionCare SM 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.
News
and information about your benefits, Trust Funds administration
and a quarterly "Calendar of Events".
News
and information about training and apprentice programs and
activities, training courses and class schedules at the Northern
California Laborers Training Center.
A
monthly informational bulletin for our valued participants
- assisting you in understanding your benefits.
