Retiree 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.
  • Retiree Health Plan Beneficiary Benefit Form (Retiree Only) — Use this form to designate the beneficiary(ies).
  • 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.
  • 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

Notice of Creditable Coverage

Plan Documents (en Español)

  • Enmienda #1 — Enmienda #1 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #2 — Enmienda #2 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #3 — Enmienda #3 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #4 — Enmienda #4 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #5 — Enmienda #5 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #6 — Enmienda #6 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #7 — Enmienda #7 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #8 — Enmienda #8 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #9 — Enmienda #9 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #10 — Enmienda #10 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #11 — Enmienda #11 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #12 — Enmienda #12 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.
  • Enmienda #13 — Enmienda #13 a la Descripción Resumida del Plan (Summary Plan Description-SPD) para la Salud de Jubilados de IBEW-NECA en la Región Sur de California es efectuada por la Junta de Síndicos de Southern California IBEW-NECA Health Trust Fund.

Plan Documents (in English)

  • Summary Plan Description — Benefits for Eligible Southern California IBEW-NECA Retirees and Their Eligible Spouses.
  • Amendment #1 — Amendment #1 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #2 — Amendment #2 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #3 — Amendment #3 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #4 — Amendment #4 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #5 — Amendment #5 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #6 — Amendment #6 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #7 — Amendment #7 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #7 — Amendment #8 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #9 — Amendment #9 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #10 — Amendment #10 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #11 — Amendment #11 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #12 — Amendment #12 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.
  • Amendment #13 — Amendment #13 to the Southern California IBEW-NECA Health Trust Fund Retiree Health Plan Summary Plan Description.

Summary of Benefits and Coverage (SBC)

Video Library

  • APV Process Video Walkthrough — Under a federal law known as ERISA, the Trustees have a fiduciary obligation to ensure that pension benefits are not paid to pensioners who are engaged in activities which could lead to the suspension of their monthly pension benefit under the Plan's Suspension of Benefit Rules. To discharge in part that fiduciary obligation, the Trustees require all pensioners to complete, on an annual basis, an Annual Pensioner Verification form. Completion and return of the form is "self-reporting" by an individual pensioner as to activities performed during the preceding calendar year. The Fund Office has prepared a video to introduce the APV process. 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).
  • Thinking about Retirement — The Fund Office has prepared a video to introduce you to the process to apply for Retiree Pension Benefits and Retiree 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).