Forms & Documents

Enrollment Documents

Enrollment Form
Change Form
Married Employees Election of Joint Coverage

Married employees, who are both covered by the Trust and are employed by signatory contractors to the Trust, may jointly enroll for health, dental and vision coverage. The employee whose birthday is first in the calendar year will be the primary covered employee and the other employee will be the dependent.

However, the employee who is covered as a dependent must be enrolled, as an employee for mental health and life insurance coverage; the employee may not opt out and must be covered for such benefits as an employee.

Options Rider Claim Form

The Options Rider benefit includes coverage for physician and outpatient services as outlined in the Summary Plan Description. Inpatient services, major surgery and maternity care are expressly excluded. This Rider is offered only in conjunction with enrollment in the Plan’s HMO benefit. Claims must be submitted to the Administrative Office, along with a completed Claim Form, within fifteen (15) months of the date of service.

Anthem Life Conversion

You have 31 days from the date your life insurance through Anthem terminates to apply for individual coverage. You must complete one of the Conversion Forms and submit it to Anthem with your first month's payment. Read the Conversion Form for more information.

Anthem Life Insurance Beneficiary Form
Accelerated Life Benefit Form
Life Waiver of Premium Form
Life Claim Form