This is one of two forms required to be completed to apply for the continuation of the participant’s Welfare Fund life insurance benefit when a participant has become totally and permanently disabled prior to reaching 60 years of age.

This is one of two forms required to be completed to apply for the continuation of the participant’s Welfare Fund life insurance benefit when a participant has become totally and permanently disabled prior to reaching 60 years of age.

A Participant, patient or Authorized Personal Representative generally has the right to appeal denial of enrollment, eligibility for benefits or a claim for benefits that was denied in whole or in part.

A covered individual may designate an Authorized Personal Representative to act on his behalf when appealing denial of enrollment, eligibility for benefits or a claim for benefits that was denied, in whole or in part, by completing an Authorized Personal Representative Designation Form and submitting it with the Appeal Form.

This document explains who qualifies for COBRA, the types of qualifying events, the maximum period of coverage, payment deadlines, the Low Cost Medical Plan, adding a dependent while on COBRA or Low Cost, reasons for termination of coverage and converting to an individual policy after you exhaust the maximum period of coverage under COBRA or the Low Cost Medical Plan.

This is one of two forms required to be completed to apply for continuation of insurance for an overage child that is permanently physically or mentally disabled.

This is one of two forms required to be completed to apply for continuation of insurance for an overage child that is permanently physically or mentally disabled.

Describes the change in determining eligibility based on the four calendar quarter hour rule.

Completion of this form is mandatory for enrollment to the Plan and required in order to add or remove your eligible dependents. This form is also used to designate the beneficiary for the life insurance benefit if applicable.

Use this form to enroll adult dependent children ages 19 to 26.

If the Appeals Committee of the Board of Trustees has maintained denial of a claim, in whole or in or part, the Participant, Patient or Authorized Personal Representative generally has the right to request an external review.

A Participant, patient or Authorized Personal Representative generally has the right request an expedited review if the adverse benefit determination involves a medical condition of the claimant for which the timeframe for the completion of a standard appeal would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function or, if in the opinion of your physician, the patient would experience pain that cannot be adequately controlled.  If the above criteria is not met, the request for an Expedited Review will be denied.

Describes the benefits available under the Low Cost.

To be completed and notarized when a natural parent does not have insurance for their child.

Application & notice to Administrator of a Qualifying Event in order to possibly extend Cobra coverage.

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

To be completed by new participants as well as on an annual basis for active participants covered by the Plan.

Explanation of the privacy notice including a form to restrict access to your protected health information (PHI).

To be completed by the natural parent and notarized to determine whether a child born out of wedlock qualifies as a covered dependent under the Plan.

To be completed to determine whether a stepchild qualifies as a covered dependent under the Plan.

To be completed when expenses for an illness or accident may be compensable by an action against a third party.

To be completed by the participant and his attending physician to apply for the Weekly Benefit for Illness or Injury.

Physician certification of continuing disability.

A Participant, patient or Authorized Personal Representative generally has the right to appeal denial of enrollment, eligibility for benefits or a claim for benefits that was denied in whole or in part.

A covered individual may designate an Authorized Personal Representative to act on his behalf when appealing denial of enrollment, eligibility for benefits or a claim for benefits that was denied, in whole or in part, by completing an Authorized Personal Representative Designation Form and submitting it with the Appeal Form.

Use this form to cancel the Retiree Healthcare Benefits for your dependent child.

Use this form to cancel the Retiree Healthcare Benefits for either yourself or your spouse.

If you, the retired carpenter, are already covered by the Retiree Healthcare Plan of Benefits, this is the information and the form that you need to add your dependent child to the plan.

If you, the retired carpenter, are already covered by the Retiree Healthcare Plan of Benefits, this is the information and the form that you need to add your spouse to the plan.

If the Appeals Committee of the Board of Trustees has maintained denial of a claim, in whole or in or part, the Participant, Patient or Authorized Personal Representative generally has the right to request an external review.

A Participant, patient or Authorized Personal Representative generally has the right request an expedited review if the adverse benefit determination involves a medical condition of the claimant for which the timeframe for the completion of a standard appeal would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function or, if in the opinion of your physician, the patient would experience pain that cannot be adequately controlled.  If the above criteria is not met, the request for an Expedited Review will be denied.

A notice describing the Plan’s prescription drug coverage and advising participant’s that the Plan’s prescription coverage is better than Medicare Part D coverage.  It is important that Medicare eligible participants do not enroll in Medicare’s Part D prescription coverage.

Describes the benefits under the Retiree Plan of Benefits.