Forms / Notices
General Forms
- Summary of Benefits and Coverage – Effective 1/1/2021 – 12/31/2021.
- 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.
Other Forms
More specific forms can be found on their own pages. See Pages under Forms / Notices, below, for details.
Pages under Forms / Notices
- 1999 Summary Annual Report
- 2002 Summary Annual Report
- 2004 Summary Annual Report
- 2005 Summary Annual Report
- 2006 Summary Annual Report
- 2008 Summary Annual Report
- 2009 Summary Annual Report
- 2010 Summary Annual Report
- April 2013, Summary of Material Modifications
- April 2014, Summary of Material Modifications
- April 2015 Notice on Dental Providers in Mexico/New Pinnacle ID Card
- April 2015, Summary of Material Modifications
- April 2015, Summary of Material Modifications
- August 2015 Notice on Medical and Dental Services in Mexico and Out-of-Pocket Costs
- Change of Address Form
- Claim Forms
- COBRA Forms
- December 2013, Summary of Material Modifications
- December 2014, Summary of Material Modifications
- December 2015 Notice of New PPO Plan Pharmacy Benefit Manager/New Medical Id Card
- Disability Credit Acknowledgement
- July 2015 Notice on Change to the Rules of Eligibility for Non-Bargaining Employees with respect to Plan A or Plan B Group Health Coverages
- July 2016, Summary of Material Modifications
- June 2014, Summary of Material Modifications
- May 2016, Summary of Material Modifications
- Medical Claim Form
- Medical Claim Form
- October 2012, Summary of Material Modifications
- October 2013, Summary of Material Modifications
- Official Plan Notices
- Physician’s Disability Certification
- Subrogation and Assignment of Benefits Form
- Subrogation Questionnaire
- Summary Annual Reports
- Summary of Material Modifications (SMMs)
- Summary of Material Modifications October 2010