Forms - Health & Welfare Forms

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:

Select the checkbox next to the document’s name (you can select as many different documents as you like).

Once your selections are made, scroll down this page and comlete your personal information.

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
Change of Address Notification	Update your mailing address.
Disability Certification Form	Apply for extended eligibility due to your absence from covered employment because of a disability.
Enrollment Form	Update marital status, add a new spouse or dependent child, designate a beneficiary and update mailing address.
Medical Expense Claim Form	File if you are: submitting a claim with itemized statements or when requested by the Fund Office.
Active Plan Benefit Application Form	Initially choose, or change your current, hospital-medical plan option.
Retired Plan Benefit Application Form	Initially choose, or change your current, hospital-medical plan option.
Application for Student Extended Dependent Coverage	Apply for extended benefits coverage for a dependent child over 19 years of age, who is a student at an accredited educational institution.
Beneficiary Designation Form	Designate to whom applicable plan benefits will be distributed after the death of the participating Laborer/Employee.
Affidavit for Stepchild Coverage	List and certify applicable stepchildren as eligible for dependent plan benefits.
Other Insurance Inquiry Form	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.
Electronic Direct Deposit Form - Vacation-Holiday	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
Employee Proof of Death Form	Notify the Fund Office of the participant's death (submitted by the surviving spouse or beneficiary).
Active Participant's Spouse or Dependent Child Death Form	Notify the Fund Office of the death of a participants spouse or dependent child (submitted by the participant).
Proof of Permanent and Total Disability for Extended Death Benefit	Apply for extended death benefits after a participant’s death, if the participant had a certified “total disability” status prior to death.
Beneficiary Enrollment Form	Enroll eligible beneficiaries of a deceased participant in order to continue applicable benefits.
Dental Benefit Plan Information
Document	Description	In-Mail Request
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.
Dental Application	Application form describing a new optional dental program for Active Laborers and their dependents.
Dental Application for Retired Laborers	Application form describing a new optional dental program for Active 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® 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
Employee Assistance Pamphlet Program	Pamphlet describing the Member Assistance Program benefit, sponsored by Claremont 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.
Anthem 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 Anthem Blue Cross® Prudent Buyer Plan PPO network, which is used to provide hospital-medical benefits to participants covered under the Trust Fund's Direct Payment Plan.
Comparison of Dental Plans	Sheet which compares the major dental plan options.
Comparison of Benefit Plans for Retired Laborers	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.
Summary Annual Report	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 (* Indicates a required field)
Name*
Health Plan ID
Address 1*
Address 2
City*
State/Province*
ZIP/Postal Code*
Email Address
Telephone Number
TeleFAX Number

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.

If you would like the document mailed to you:

Miscellaneous Benefits & Trust Funds Information

Personal Information (* Indicates a required field)

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.

Personal Information
(* Indicates a required field)

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.