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.

Disability

General

  • 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.
  • Prescription Drug Card Program – San Francisco Electrical Workers and Catamaran 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.
  • Catamaran Mail Order Brochure – Use this form to order prescription drugs or refills.
  • 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.

HIPAA

Legally Required

Notices

  • 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.

SBCs