Summary of Benefit Coverage

• 2025 Plan A – Anthem Blue Cross PPO – Effective 1/1/25 – 12/31/2025
• 2025 Plan A – Sharp HMO – Effective 1/1/25 – 12/31/2025
• 2025 Plan A – Kaiser HMO – Effective 1/1/25 – 12/31/2025
• 2025 Plan B – Kaiser HMO – Effective 1/1/25 – 12/31/2025
• New option 2025 Plan B – Sharp HMO – Effective 1/1/25 – 12/31/2025

General Forms

• Health & Welfare Enrollment Card – This card is used for your group health enrollment and record.
• Change of Address Form – Use this form to change your address. Be sure to fill it out completely and return it to the Trust Office.
• Disability Credit Acknowledgement – Use this form to acknowledge “Disability Credit” responsibilities and limitations.
• Physician’s Disability Certification – A participant’s physician must use this form to certify a participant’s disability.
• 2025 Participant Information & Coordination of Benefits Questionnaire – Before any 2025 claims can be processed, you must complete this form and returnit to the Trust Office.
• 2024 Participant Information & Coordination of Benefits Questionnaire  – Before any 2024 claims can be processed, you must complete this form and return it to the Trust Office.

Other Forms

More specific forms can be found on their own pages. See Pages under Forms / Notices, below, for details.