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.

RX America 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 RxAmerica are pleased to provide the retail and mail order prescription program to the self-funded indemnity plan. Please review the following information provided to help you best utilize the pharmacy program.

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.

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.

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).

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.

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.