ONLINE FORMS

Annual Funding Notice (Pension & Annuity)

  1. Pension & Annuity Plan Year Ending April 2022 - Annual Funding Notice
  2. Pension and Annuity Plan Year Ending 2021 - Annual Funding Notice

Health & Welfare

  1. 2022 COB-Active
  2. 2022 COB-Retired
  3. Affordable Care Act Section 1557 Notice
  4. Benefit Fund Direct Deposit Form
  5. Census and Beneficiary Designation Form
  6. Change of Address Form
  7. Cigna Dental Benefit Summary
  8. Cigna Dental FAQs
  9. Davis Vision Benefit Summary
  10. Davis Vision Member FAQs
  11. Express Scripts Claim Form
  12. Health & Welfare Federal Acts & Guidelines Notice
  13. HRA Claim Form
  14. Maiden Name Form
  15. Notice of COBRA Rights
  16. Patient First Physical Exam Authorization Form
  17. Spouse Employment Verification Form
  18. Summary of Benefits and Coverage 2022 - Class I
  19. Summary of Benefits and Coverage 2022 - Class II
  20. Vision Benefit Direct Reimbursement Form

HIPAA

  1. Notice of Privacy Practices

Hours Department

  1. Benefit Fund Direct Deposit Form
  2. Change of Address Form
  3. Dependent Care Reimbursement Form
  4. Reciprocal Form

Medicare

  1. Blue Medicare Advantage Plan - Evidence of Coverage (2022)

Retirement Funds

  1. 2022 COB-Retired
  2. Benefit Fund Direct Deposit Form
  3. Carpenters Savings Plan Quick Start Guide
  4. Change of Address Form
  5. Tax Form for Monthly Annuity (W-4)
  6. Tax Form for Monthly Pension (W-4)

Summary Annual Report (Health & Welfare)

  1. Health & Welfare Plan Year Ending April 2021 - Summary Annual Report (SAR)

Summary Annual Report (Savings Plan)

  1. Savings Plan Year Ending April 2021 - Summary Annual Report (SAR)

Summary of Material Modification (SMM) - Health & Welfare

  1. Health & Welfare Plan SMM (5.1.2022)
  2. Radiology, Orthotics, Virta (SMM 2022)

Summary Plan Description (SPD Documents)

  1. Carpenters Health & Welfare Plan (May 2020)- Summary Plan Description (SPD)
  2. Carpenters Pension and Annuity Plan (May 2020) - Summary Plan Description (SPD)
  3. Carpenters Retiree Health & Welfare Coverage (Jan 2021) - Summary Plan Description (SPD)
  4. Carpenters Savings Plan (May 2020) - Summary Plan Description (SPD)
  5. Independence Administrators Benefit Booklet (Basic Coverage) (SPD)
  6. Independence Administrators Benefit Booklet (Full Coverage) (SPD)