Health & Welfare Forms

The following is a list of Health and Welfare plan forms and informational publications that can be requested from the Fund Office.

Some of the plan documents may be available for online viewing in the PDF file format. Adobe's Acrobat Reader is required.

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General Health & Welfare Forms
Document Description
Enrollment Form Update marital status, add a new spouse or dependent child, designate a beneficiary and update mailing address.
Active Plan Benefit Application Form Initially choose, or change your current, hospital-medical plan option.
Retired Plan Benefit Application Form Initially choose, or change your current, hospital-medical plan option.
Change of Address Notification Update your mailing address.
Disability Certification Application for extended eligibility due to absence from covered employment because of a disability.
Handicapped Child Disability Certification Start or continue benefit coverage for a handicapped, dependent child.
Affidavit for Foster or Stepchild Coverage Establish dependent coverage for a foster child or stepchild.
Application for Student Extended Dependent Coverage Application form to extend benefit coverage for a dependent child who is over 19 years of age and a student at an accredited educational institution.
Electronic Direct Deposit Authorization for Vacation Benefit Checks Authorization for the Trust Funds to electronically send your Vacation benefit checks to your designated financial institution. Faster, convenient and more secure than mailing checks to an address.
Death Notification & Benefit Application Forms
Document Description
Employee Proof of Death Notify the Fund Office of the participant’s (Cement Mason’s) death (submitted by the spouse or beneficiary)
Dependent Proof of Death Notify the Fund Office of the death of a spouse or dependent child (form submitted by the participant)
Beneficiary Enrollment Form Form to enroll eligible Beneficiaries/Dependents, of a Deceased Participant/Pensioner, in order to continue applicable Health and Welfare Plan benefits.
Dental Benefit Plan Information
Document Description
Active Dental Plan Pamphlet Description of dental benefits for Active Cement Masons and their dependents.
Retired Dental Plan Pamphlet Description of dental benefits for Retired Cement Masons and their dependents.
 DeltaPreferred Option (DPO)
Optional Dental Plan
Pamphlet describing a new optional dental benefits program for Active and Retired Cement Masons and their dependents.
Dental Application Application form describing a new optional dental benefits program for Active and Retired Cement Masons and their dependents.
Pharmacy Benefits Plan Information
Document Description
 Prescription Solutions® Mail Service Pharmacy Application Form Pamphlet, with enrollment form, describing a prescriptions-by-mail service offered as part of the Pharmacy benefit.
 Prescription Solutions® Prescription Drug Program Direct Member Reimbursement Form Complete and return this form when you have purchased a covered, prescribed prescription drug at retail cost and are seeking reimbursement.
 Vision Benefits Plan Information
Document Description
 Vision Plan Pamphlet Description of vision benefits for Cement Masons and their dependents.
Miscellaneous Benefits & Trust Funds Information
Document Description
 The Cement Mixer Quarterly Newsletter News and information about your benefits, Trust Funds administration and a quarterly "Calendar of Events".
The Benefit Bulletin Monthly Newsletter A monthly informational bulletin for our valued participants –assisting you in understanding your benefits.
 Blue Cross® of California's PPO Prudent Buyer Plan® Directory of Health Care Professionals & Institutions Directory of hospitals, physicians, ambulance services, ambulatory surgery centers, mental health facilities, hospice providers, home health agencies, home infusion therapy providers, laboratories, medical products/service providers, skilled nursing facilities, dialysis centers and ancillary medical providers participating in the Blue Cross® Prudent Buyer Plan PPO network, which is used to provide hospital-medical benefits to participants covered under the Trust Fund's Managed Health Care Plan.