Active Health Plan Forms

Complete & Print Forms - You can complete most of the forms listed below right on your computer before you print. Simply click on a field in the form and type in the appropriate information. Then print the completed form, sign and mail it to the Trust Office. These printable forms are in PDF format. To read and print them, you need the free Adobe Reader (which is probably already installed in your system). Click here if you do not have Adobe Reader installed on your system.

Claim Form

Enrollment/Eligibility

General

  • HIPAA Privacy Notice — The Southern California IBEW-NECA Health Plan may use the limited quantity of private health information available, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), for purposes of making or obtaining payment for your care and conducting health care operations.
  • Life and Accidental Death & Dismemberment Insurance/Beneficiary Designation Form (Active Only) — Use this form to designate beneficiary(ies) for Life and Accidental Death and Dismemberment Insurance.
  • Change of Address — Use this form to change your address. Be sure to fill it out completely and return it to the Trust Office. (English Version)
  • Forma Para Solicitar Cambio De Dirección (En Español) — Use esta forma para hacer un cambio de dirección postal.  Asegúrese de completar todos los espacios en la forma, y de enviar la misma a la oficina del Trust Funds.
  • Workers Compensation form (Active Only) — Complete this form for consideration of benefits.
  • HIPAA Participant Authorization Form — Use this form to instruct the Fund Office to communicate with you at an alternate address regarding your eligibility, carrier changes, etc.

Legally Required

Plan Documents (en Español)

  • Descripción resumida del Plan — Para los participantes activos elegibles y sus dependientes elegibles.
  • Suplemento a la Descripción Resumida del Plan — Para Aprendices/Participantes de Unidad de Sonido Elegibles a sueldo del 45% y del 50% y sus Dependientes Elegibles.
  • Enmienda #1 — Enmienda #1 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #2 — Enmienda #2 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #3 — Enmienda #3 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #4 — Enmienda #4 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #5 — Enmienda #5 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #6 — Enmienda #6 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #7 — Enmienda #7 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #8 — Enmienda #8 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #9 — Enmienda #9 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.
  • Enmienda #10 — Enmienda #10 a la Descripción Resumida del Plan (Summary Plan Description - SPD) del Fondo de Fideicomiso para la Salud IBEW-NECA en la Región Sur de California para Participantes Elegibles Activos y sus Dependientes Elegibles.

Plan Documents (in English)

  • Summary Plan Description — For Eligible Active Participants and Their Eligible Dependents.
  • Summary Plan Description Supplement — For Eligible Sound Unit 45% & 50% Apprentices/Participants and Their Eligible Dependents.
  • Amendment #1 — Amendment #1 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #2 — Amendment #2 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #3 — Amendment #3 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #4 — Amendment #4 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #5 — Amendment #5 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #6 — Amendment #6 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #7 — Amendment #7 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #8 — Amendment #8 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #9 — Amendment #9 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.
  • Amendment #10 — Amendment #10 to the Southern California IBEW-NECA Health Trust Fund Summary Plan Description for Eligible Active Participants and their Eligible Dependents.

Summary of Benefits and Coverage (SBC)

Video Library

  • Review of Plan Eligibility — The Fund Office has prepared a video to understand how to gain and maintain eligibility in the SC IBEW-NECA Health Plan. Take a brief tour and review the video. The video is not a substitute for the Summary Plan Description. Prior to filing any application for benefits, you should thoroughly review the Summary Plan Description (SPD).