Application for Hour Bank Advance for Non-COBRA Continuation Coverage - Effective for October 2009 work hours (December 2009 coverage), the Plan has been amended to allow for an hour bank advance of up to 120 hours for active members to prevent loss of coverage. Use this application to apply. Note: this benefit is scheduled to expire effective with March 2010 hours (May 2010 coverage).

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

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

Enrollment Card - Use this card for initial enrollment or to report changes to dependent 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.

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.

Retail 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 following information provided to help you best utilize the pharmacy program.

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.

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.

Disability Claim Notice - This claim form is used to apply for disability claims.

Physician's Statement of Disability - This form is used to determine long-term disability coverage and must be completed by a licensed doctor.

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.

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

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.

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.

2009 Medical Plan Information: Active - This is the Open Enrollment Package for 2009 containing the open enrollment information.

2009 Medical Plan Information: Retiree - This is the Open Enrollment Package for 2009 containing the open enrollment information.

Open Enrollment - 401k Election for 2009 - In accordance with the collective bargaining agreement, if you have attained at least journeyman level and you are working for an employer that contributes to the San Francisco Electrical Workers Retirement Savings Plan, you may elect (or revise your current election) to make 401(k) pre-tax wage deferrals during open enrollment.

Notice of Privacy Practices - This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

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.

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.

Summary of USERRA Rights - The following represents a summary of the rights afforded to Plan Participants who are ordered to active military service (USERRA Rights) as they relate to the Northern California Electrical Workers Pension Trust and the San Francisco Electrical Workers Health & Welfare Plan.

Member Assistance Plan - San Francisco Electrical Workers Trust Fund is pleased to offer a Member Assistance Program (MAP) benefits to ALL its’ members, insured dependents and their household members. It is provided by PacifiCare Behavioral Health (PBH).

Notice of Changes to Health & Welfare Summary Plan Description - 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.

2008 Medical Plan Information: Active - This is the Open Enrollment Package for 2008 containing the open enrollment information.

2008 Medical Plan Information: Retiree - This is the Open Enrollment Package for 2008 containing the open enrollment information.

2008 Summary of Material Modifications (Self Funded PPO Plan Only) - Summary of material modifications to the Self Funded PPO (formerly Indemnity) Plan.

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.

New Retiree Co-Payment Rates Effective 1/1/2008 - A report from the Plan Consultants on revisions to early retiree co-payments, effective 1/1/2008.

Change to RxAmerica Mail Service (Indemnity Plan only), Effective 7/20/2007 - Effective July 20, 2007, your prescription mail order service is being improved to better serve you. This change will provide you with superior service and the latest technology in mail order pharmacy. There will be no interruption in service due to the change. This document contains an outline of what will change for you and what will not change.

401(k) Election and Salary Reduction Agreement for 2007 - This form was used to make 401(k) deferrals from your 2007 hourly wages to your account in the San Francisco Electrical Workers Retirement Savings Plan for 2007. This form must have been returned by December 8, 2006 - if no form was received, you would have been treated as having a 401(k) elective deferral in 2007 based on your 2006 Money Purchase Classification.

New Retiree Co-Payment Rates Effective 1/1/2007 - The Northern California Electrical Workers Money Purchase Pension Plan is being converted to a 401(k)/profit sharing plan effective for all hours worked after December 31, 2006. This change is being made to reflect various changes in tax and pension laws over the past few years, and to give participants more flexibility to vary their contributions to the Plan depending on their own circumstances.

Enhanced Prescription Benefits for San Francisco Electrical Workers - Beginning August 1st 2006 you will now have the option of obtaining maintenance prescriptions written for an 84 day supply but not greater than a 90 day supply exclusively at the retail chain pharmacy Longs Drugs Stores. You will continue to be responsible for the 20% copay for both brand and generic medications at the time of purchase.

Changes to the Plan in 2006 - A summary of the decisions that were made by the Trustees in efforts to improve the program while controlling Plan costs in 2006.

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

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.