For Participants > Downloads


Health and Welfare

Annual Notices - Active

Anthem Member Assistance Program (MAP)

Delta Dental Claim Form (Excludes Retirees)

Delta Dental Evidence of Coverage (Excludes Retirees)

Disability Benefit Application English or Español

Domestic Partner Application English or Español

Enrollment Form English or Español

Express Scripts® Information (Indemnity Only)

Express Scripts® Mail Order Prescription Form (Indemnity Only)

Express Scripts® Prescription Drug Reimbursement Form (Indemnity Only)

General Statement of Nondiscrimination

Hearing Aid Claim Form

Medical Claim Form (Indemnity Active Carpenters Only)

Notice of Creditable Coverage

Notice of Privacy Practices

Orthodontic Claim Form

Physical Exam Form (Indemnity Only)

Protected Health Information Authorization Form English or Español

Protected Health Information Revoke Authorization Form English or Español

Search for Indemnity Plan Providers (Instructions)

Supplemental Weekly Disability Continuation Form

Value Based Facilities for Knee & Hip Replacement Surgeries

Health and Welfare: Plan A and R

Plan Comparison English or Español

Summary Plan Description - Rules & Regs - Amendments

Health and Welfare: Plan B and Flat Rate

Plan Comparison English or Español

Summary Plan Description - Rules & Regs - Amendments

Health and Welfare: Retiree

Health and Welfare Self Pay Rates

Medical Claim Form (Indemnity Retirees Only)

Plan Comparison English or Español

Retiree Dental Enrollment Form and Rates

Retiree Dental Evidence of Coverage for Retired Participants who have No Lapse in Coverage

Retiree Dental Evidence of Coverage with Lapse in Coverage

Summary Plan Description - Rules & Regs - Amendments

 
Pension

Annual Funding Notice & Notice of Critical Status

Application for Retirement English or Español

California EDD Form DE 4P - Withholding Certificate for Pension or Annuity Payments

Direct Deposit Election Form English or Español

Disability Benefit Application English or Español

IRS Form W-4P - Withholding Certificate for Pension or Annuity Payments

Notice to Interested Parties

Report of Summary Plan Information

Retirement 101

Sample Qualified Domestic Relations Order (QDRO) for Active Participants

Sample Qualified Domestic Relations Order (QDRO) for Retired Participants

Summary Plan Description - Rules & Regs - Amendments English or Español

 
Annuity

Application for Withdrawal English or Español

California EDD Form DE 4P - Withholding Certificate for Pension or Annuity Payments

Direct Deposit Election Form English or Español

Fee Disclosure Notice

IRS Form W-4P - Withholding Certificate for Pension or Annuity Payments

Notice to Interested Parties

Retirement 101

Sample Qualified Domestic Relations Order (QDRO)

Self-Direct Annuity Online Seminar

Self-Direct Transfer Form

Self-Direct Transfer Form - Return Monies to the Trustee-Directed Account

Summary Plan Description - Rules & Regs English or Español

 
Northern California Carpenters 401(k) Plan

Beneficiary Designation Form English or Español

Enrollment/Contribution Change Form English or Español

Fee Disclosure Notice

Notice to Interested Parties

Retirement 101

Safe Harbor Notice

Summary Plan Description - Rules & Regs

 
Vacation

Early Withdrawal Application English Español

Direct Deposit Form for Benefit Payments

Summary Plan Description - Rules & Regs - Amendments English or Español

 
General

Address Change Form English or Español

Beneficiary Designation Form English or Español

Bereavement Leave Claim Form for Mill Cabinet Employees

Check Stub Claim Form (Report Missing Hours)

Disability Packet English or Español

Electronic Delivery Election Form English or Español

Enrollment Form English or Español

Notice of Privacy Practices

HIPAA Privacy Notice & Women's Health & Cancer Rights

Protected Health Information Authorization Form

Reciprocity Request - Transferring Hours to Northern California

Summary Annual Reports

 
Employee Retirement Income Security Act of 1974 (ERISA)

Plans A, B, R, Flat Rate

 
Annual Mailings

Your Annual Mailing Packet will contain some or all of the following documents, depending upon which plans you are currently active in:

  • Electronic Delivery of Plan Materials
  • Summary of Benefits & Coverage
  • Notice of Creditable Coverage
  • Reminder to Provide the Plan with your Identification Number (and Family Members' Identification Numbers, if Applicable)
  • Option to Decline Dental Plan and/or Vision Plan Coverage
  • Health Insurance Portability & Accountability Act (HIPAA) Notice of Privacy Practices for Protected Health Information (PHI)
  • Women's Health & Cancer Rights Act (WHRCA) Notice
  • Special Extension of Coverage for Certain Dependent Students on a Medically Necessary Leave of Absence
  • Disclosure of "Grandfather" Status
  • Medicaid and the Children's Health Insurance Program (CHIP) Notice Offer Free or Low-Cost Health Coverage to Children and Families
  • Summary Annual Reports
  • New York Life Retirement Plan Services Merged into John Hancock Retirement Plan Services
  • Fee Disclosure Notice

Annual Mailing Packets are categorized as follows:

SBC Glossary of Health Coverage & Medical Terms

 

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