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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 complete 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.
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.
Initially choose, or change your current, hospital-medical plan option.
Initially choose, or change your current, hospital-medical plan option.
Designate to whom applicable plan benefits will be distributed after the death of the employee.
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.
Authorization for the Trust Funds to electronically send your Health Care Expense Assistance Benefit 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
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 Laborers and their dependents.
Application form describing a new optional dental program for Retired Laborers and their dependents.
Pharmacy Benefits Plan Information
Document
Description
In-Mail Request
Pamphlet, with enrollment form, describing a prescriptions-by-mail service offered as part of the Pharmacy benefit.
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
Pamphlet describing vision benefits for Active Laborers and their dependents.
Pamphlet describing optional vision benefits for Retired Laborers.

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.
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.
Sheet which compares dental plans options.
Sheet which compares the hospital-medical benefits, offered by the Trust Fund's Managed Health Care Plan and any Kaiser, to Retired Laborers.
Sheet which compares the hospital-medical benefits, offered by the Trust Fund's Managed Health Care Plan and any Kaiser, 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 participants to assist 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.