FORMS / DOCUMENTS

CLAIMS FORMSELIGIBILITY FORMS (RECIPROCITY, COBRA, RETIREE)EMPLOYER FORMSDOCUMENTS

Enrollment Form
Claim Form
Adult Dependent Enrollment Form
Adult Dependent Disenrollment Form
Loss of Time Disability Form
Subrogation Form and Agreement
Statement of Total Disability (for Extension of Active Death Benefit)
Death Benefit Claim Form
Affidavit of Survivorship Form
Accidental Dismemberment Claim Form
Authorization for Release of Protected Health Information (PHI)
Privacy Notice

Employee Reciprocal Authorization Form
COBRA Election Form – Construction
COBRA Election Form – NonConstruction
Retiree Election Form
Direct Payment Authorization Form
Termination of Direct Payment Form
Spouse Delayed Retiree Election Form

Construction Employer Contribution Form
NonConstruction Employer Contribution Form

Plan Document Revised November 2021
Summary of Material Modification Mailed February 2022
2022 SBC – Active Plan
2022 SBC – Retiree B Plan
2022 SBC – Retiree H Plan
Summary of Material Modification – Mailed August 2022
Trust Agreement Restated July 2005 and Amendments
Delinquency Procedures

Information provided in this website is subject to occasional changes in Plan benefits and policies and is therefore not guaranteed. Please contact the Fund Office if you have questions concerning any of the information in this website.