Health & Welfare
Plans
Self-funded PPO
Kaiser HMO Plan
Benefits
Actives
Useful Links
Retirees
Forms
- Application for Coverage as a Retiree for Health & Welfare Benefits Prefunded
- Application for Coverage as a Retiree for Health & Welfare Benefits Retiree
- Dental Claim Form
- Hartford Enrollment Form
- Health Net ENR Form
- Health Net Prescription Drug Plan Enrollment Form
- Kaiser HMO Enrollment Form
- Outpatient Rx Enrollment Form
- SSA CMS Application form L564
- United HealthCare Enrollment Form
- United HealthCare Enrollment Request Form
- United HealthCare Prescription Drug Plan Enrollment Form
Documents
- Dental PPO Plan Summary of Benefits
- GRIP II WA GRH Hartford Summary of Coverage
- Hartford IBEW Medical Benefit Chart 3777
- Hartford Summary of Coverage
- Health Net Schedule of Benefits and Coverage
- Kaiser Permanente Chiropractic Plan
- Kaiser Permanente Summary of Benefits
- United Healthcare Benefit Highlights
- Vision Benefits Summary
- VSP at your fingertips
- VSP Grievance Process Notice
Useful Links
Pension
Forms
- Address Change Form
- Beneficiary Designation Form
- California Tax Withholding Form (EDD)
- Electronic Funds Transfer Form
- Federal Tax Withholding Form (2022 W4P)
- Health & Welfare Withholding Form
- Qualified Domestic Relations Order Sample (Active Member)
- Qualified Domestic Relations Order Sample (Retired Member)
Defined Benefit
Defined Contribution & 401K Plan
Forms
- Long-Term Disability Part B Application Packet
- Part B Pension Application Packet
- Part B Change Investment Form
- Part B Distribution Form (married)
- Part B Distribution Form (single)
- Application For Plan Loan
- Distribution/Rollover Election Form
- Mandatory Payment of Small Account Balance
- Beneficiary Designation Form
- Application For Plan Loan