Enrollment Form for Active Members - Use this card for initial enrollment or to report changes in enrollment status. Note: Dependents are generally eligible if enrolled when you first enroll, or within 30 days of marriage, domestic partnership, birth, adoption, etc. If not, you must wait until the Plan's open enrollment period, unless you have delayed enrollment under the Plan's Special Enrollment provision.

Enrollment Form to Add an Adult Child Age 19 Through 25 - An Adult Child age 19 through 25 may be eligible for coverage on the same basis as dependent children under the Plan provided the Adult Child is not eligible to enroll in group medical insurance other than through a plan that covers the other parent. Use this form to enroll him or her. [Note: this “other coverage” rule will no longer apply when/if the Plan loses grandfather status.]

Application for Retiree Health and Welfare Coverage - This form is used to apply for Retiree Health and Welfare Coverage.

Application for Early Retiree Membership - Use this form to apply for early retiree membership.

Declaration of Domestic Partnership For Enrollment and Eligibility - Coverage for the Domestic Partner will begin on the first day of the following month upon submission of the fully executed and notarized original of this form (please keep a copy for your records).

Death Benefit Claim - Use this form to claim death benefits. A certified copy of the official death certificate must be attached and sent to the Trust Fund Office.

Prescription Drug Card Program - San Francisco Electrical Workers and CVS Caremark are pleased to provide the retail and mail order prescription program to the Self-funded PPO Plan. Please review the summary provided to help you best utilize the pharmacy program.

CVS Caremark Mail Order Brochure - Use this form to order prescription drugs or refills.

Subscriber’s Statement of Claim - This claim form is for participants in the PPO Self Funded Plan whose providers did not bill the Plan directly. Use this form to apply for reimbursement.

Notice of Privacy Practices - The Plan is required under the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") to maintain the privacy of your protected health information. This notice details the policy and your rights relating to your protected health information.

Participant Authorization Form - Use this form to disclose health information in the manner deemed necessary by the Health Plan in compliance with applicable law.

Request For Restrictions On Use and/or Disclosure Of Protected Health Information - Request a restriction on the San Francisco Electrical Workers Health & Welfare Plan’s (Health Plan) use and/or disclosure of your health information.

Participant Request For Confidential Communications - Use this form to request that the Health Plan communicate with you in the alternative manner and/or location regarding health information.

Request for Access to Protected Health Information - Request a copy of health information from the San Francisco Electrical Workers Health for specific dates.

Application for Temporary Health & Welfare Coverage - Use this form to apply for temporary disability Health & Welfare coverage.

Long Term Disability Application - This claim form is used to apply for monthly disability claims.

Physician's Statement of Disability - This form must be completed by a licensed doctor to support an application for Temporary Disability and/or Long Term Disability benefits.

Application for 6-month Extension of Long Term Disability Benefits - Use this form to apply for a maximum 6-month extension for long-term disability coverage.

Medical Extension Form Attending Physician's Statement - This form must be completed by an attending physician in order to extend long-term disability coverage past the 13th month.

July 2011: Plan Changes Announcement - The notice describes various changes to the Plan.

Notice of Changes to Health & Welfare Summary Plan Description (2010/2011) - The Board of Trustees of the San Francisco Electrical Workers (SFEW) Health & Welfare Plan approved several changes to the SFEW Health & Welfare Plan (Plan), effective October 1, 2010, or February 1, 2011, depending on the change. This form provides a summary of those modifications. You can also click here to view the Amendment itself.

Notice About the Early Retiree Reinsurance Program - The Early Retiree Reinsurance Program (ERRP) is a federal program that was established under the Affordable Care Act. The SFEW Health and Welfare Plan (Plan) has been approved to receive reimbursements from the limited funds available under the ERRP to help defray some of the costs of health care benefits paid on behalf of, or by, early retirees and certain family members of early retirees.

June 2010: Plan Changes Announcement - The notice describes various changes to the Plan.

Notice on "Grandfathered Plan Status" Under the Affordable Health Care Act - Please note that the Trustees believe that the San Francisco Electrical Workers Health & Welfare Plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. (Grandfather status applies only to the Self Funded PPO Plan.)

June 2009: Plan Changes Announcement - The notice gives the dates of the 2009 Open Enrollment period and describes various changes to the Plan intended to reduce costs and preserve the overall financial stability of the Fund during the fiscal period starting August 1, 2009.

Change to CVS Caremark Effective 10/1/2009 - Beginning October 1, 2009, your prescription drug plan administrator (formerly known to you as RxAmerica) will be known as CVS Caremark. Beginning October 1, 2009, you will hear the CVS Caremark name when you call the toll-free number on your ID card and see the CVS Caremark logo on the company’s Web site. Your new printed materials (e.g., forms, brochures, etc.) will carry the CVS Caremark name and logo.

Notice of Changes to Health & Welfare Summary Plan Description (2009) - The Board of Trustees of the San Francisco Electrical Workers (SFEW) Health & Welfare Plan approved several changes to the SFEW Health & Welfare Plan (Plan), effective August 1, 2009. This form provides a summary of those modifications.

Blue Shield Shared Advantage Program - The First Health Preferred Provider Network, Special Transplant Benefit Management, and Case Management was replaced with the Blue Shield Shared Advantage Program on November 1, 2008. These changes affected Indemnity (now Self Funded PPO) Plan members and dependents only. For more information, view the form linked below.

Notice of Changes to Health & Welfare Summary Plan Description (2008) - The Board of Trustees of the San Francisco Electrical Workers Health & Welfare Trust (the “Plan”) approved several amendments to the Plan effective on January 1, 2008. Those changes are summarized in this document.

Important Notice About Your Prescription Drug Coverage and Medicare - Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with San Francisco Electrical Workers and prescription drug coverage available for people with Medicare.

New RxAmerica Policy - Changes to the RxAmerica policy (now CVS Caremark) as of 9/1/2008.

San Francisco Electrical Workers Now Covers Prilosec OTC® (Indemnity Plan Only) - Prescription strength Prilosec® is now available over-the-counter (OTC) for a $0.00 co-pay. Prilosec OTC® is a proton pump inhibitor used to treat chronic heartburn. Using this medication instead of more costly alternatives is a great way to save money on your prescription drug costs.

Changes to the Plan in 2008 - A summary of the decisions that were made by the Trustees in efforts to improve the program while controlling Plan costs in 2008. Unless noted otherwise, all changes became effective on August 1, 2008.

San Francisco Electrical Workers Now Covers OTC Antihistamines - San Francisco Electrical Workers has added over-the-counter antihistamines, Claritin, Alavert and Loratadine to their prescription drug coverage. Antihistamines are used to stop or prevent allergic reactions. Members will have a $0.00 copay for these antihistamines. The changes to the plan were effective November 1, 2006.

COBRA Continuation Coverage - Further Extension of Premium Assistance (Updated March 2010) - The American Recovery and Reinvestment Act of 2009 (ARRA), as amended on March 2, 2010 by the Temporary Extension Act of 2010, provides for premium reductions for health benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985, commonly called COBRA. Eligible individuals pay only 35 percent of their COBRA premiums and the remaining 65 percent is paid by the Welfare Plan and reimbursed to the coverage provider through a tax credit. This notice describes the criteria according to which individuals may qualify for premium reduction.

COBRA Premium Assistance Extension Notice - The purpose of this notice is to explain certain features of the COBRA Subsidy that changed on December 19, 2009

Summary of the COBRA Premium Reduction Provisions under ARRA - President Obama signed the American Recovery and Reinvestment Act (ARRA) on February 17, 2009. The law gives "Assistance Eligible Individuals" the right to pay reduced COBRA premiums for periods of coverage beginning on or after February 17, 2009 and can last up to 9 months.

Summary of Continuation Coverage Rights Under COBRA and State Law - This notice contains important information about your right to purchase COBRA continuation coverage, which is a temporary extension of health coverage under the Plan.

Notice of USERRA Rights - This Notice summarizes your rights as a Participant in the Northern California Electrical Workers Pension Trust (the "Pension Plan"), the San Francisco Electrical Workers Retirement Savings Plan (the "RS Plan") and the San Francisco Electrical Workers Health & Welfare Plan (the "H&W Plan" and, collectively, the "Plans") under the Uniformed Services Employment and Reemployment Rights Act of 1994 ("USERRA"). USERRA protects you if you are ordered to active military service.

Summary Annual Report - Plan Year Ending 1/2010 - This is the Summary Annual Report for the Plan year ending January 31, 2010.

Summary Annual Report - Plan Year Ending 1/2009 - This is the Summary Annual Report for the Plan year ending January 31, 2009.

Summary Annual Report - Plan Year Ending 1/2008 - This is the Summary Annual Report for the Plan year ending January 31, 2008.

Summary Annual Report - Plan Year Ending 1/2007 - This is the Summary Annual Report for the Plan year ending January 31, 2007.

Summary Annual Report - Plan Year Ending 1/2006 - This is the Summary Annual Report for the Plan year ending January 31, 2006.

Summary Annual Report - Plan Year Ending 1/2005 - This is the Summary Annual Report for the Plan year ending January 31, 2005.

Women's Health and Cancer Rights Act of 1998 - On October 21, 1998, President Clinton signed the Omnibus Appropriations Bill which included a new federal law called the Women's Health and Cancer Rights Act of 1998.