Health and Welfare Plan Forms

Complete & Print Forms - You can complete most of the forms listed below right on your computer before you print. Simply click on a field in the form and type in the appropriate information. Then print the completed form, sign and mail it to the Plan Office. These printable forms are in PDF format. To read and print them, you need the free Adobe Reader (which is probably already installed in your system). Click here if you do not have Adobe Reader installed on your system.



  • Pregnancy Leave Benefit Clarification – This Notice clarifies the conditions for receipt of the SFEW Health & Welfare Plan's Supplemental Parental Leave benefits, with updated eligibility rules commencing, effective June 1, 2023.
  • Pregnancy Leave Benefit Application – Complete this form and return it to EISB to claim Pregnancy Leave Benefits as described in the Plan document and Summary Plan Description.
  • Leave Benefits and Long Term Disability Benefit – Emergency Leave Benefit, Pregnancy Leave Benefit and Long Term Disability Benefit.
  • Coverage for Over-the-Counter (OTC) At-Home COVID-19 Test Kits – Under a new federal mandate, your plan covers OTC at-home COVID-19 tests. Find out which tests are covered, where you can purchase tests at a $0 copay, or how your plan will reimburse you.
  • Beat It! – New Employee Assistance Program – The Board of Trustees is pleased to announce that Beat It! will provide Employee Assistance Program services starting November 1, 2020.
  • Summary of Material Modification/Important Notice Regarding Temporary COVID-19 Benefit Changes and Teladoc – The Board of Trustees has approved several changes to the Plan to provide some relief in response to the novel coronavirus disease, COVID-19, pandemic ("Coronavirus").
  • Teladoc Flyer – Get care when and where you need it through your San Francisco Electrical Workers plan. As a member, you have access to Teladoc's national network of U.S. board-certified physicians, licensed in California. Whenever you need care, Teladoc doctors are available 24/7 by phone or video.
  • Health Reimbursement Arrangement (HRA) Claim Form – Use this form to submit a claim for reimbursement from your Health Reimbursement Arrangement (HRA) account.
  • Health Reimbursement Arrangement Expenses – Summary of general categories of eligible and ineligible expenses.
  • 2018 Benefit Changes – In recent months, the Board of Trustees of the San Francisco Electrical Workers Health & Welfare Plan has approved several changes to the Plan. This notice briefly describes these changes and includes several notices that you should read and keep with your Summary Plan Description booklet.
  • 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.
  • New Parental Leave Benefit - August 2018 – The new collective bargaining agreement that became effective June 1, 2018, provides for an Employer contribution to the SFEW Health & Welfare Plan to fund a new parental leave "supplemental benefit" that supplements the state-provided California Paid Family Leave (CPFL) benefit to bond with a new child entering the family through birth, adoption or foster care placement.
  • Application for Supplemental Parental Leave Benefits – Complete this form if you are eligible to receive supplemental cash payments from the Plan for parental leave.
  • 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.
  • Optum Mail Order Form – Use this form for new prescription orders and maintenance refills for home delivery.
  • Optum Home Delivery – Benefits of medication home delivery.
  • Optum Generics – Five things to know about generic medications.
  • Direct Member Reimbursement – Use this form to submit prescription claims pending receipt of your prescription drug card, or in cases when prescription users purchase over-the-counter was reinstated retroactively.
  • 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.
  • Health Reimbursement Arrangement – As an eligible Participant with a Health Reimbursement Arrangement (HRA) account, you will be able to use the funds in your account starting January 1, 2019.


Legally Required


  • Coverage for Over-the-Counter (OTC) At-Home COVID-19 Test Kits – Under a new federal mandate, your plan covers OTC at-home COVID-19 tests. Find out which tests are covered, where you can purchase tests at a $0 copay, or how your plan will reimburse you.
  • New Evidence of Coverage and Disclosure booklet – This Evidence of Coverage and Disclosure Form booklet describes the terms and conditions of coverage of your Blue Shield health Plan. Please read this Evidence of Coverage and Disclosure Form carefully and completely so that you understand which services are covered health care services, and the limitations and exclusions that apply to your Plan.