ONLINE FORMS

Annual Funding Notice (Pension & Annuity)

  1. Pension & Annuity Plan Year Ending April 2022 - Annual Funding Notice (CBF)
  2. Pension and Annuity Plan Year Ending December 31, 2022 - Annual Funding Notice (CBF)
  3. Pension and Annuity Plan Year Ending December 31, 2022 - Annual Funding Notice (NCF)

Health & Welfare

  1. 2022 COB-Active
  2. 2022 COB-Retired
  3. Affordable Care Act Section 1557 Notice
  4. Beneficiary Designation Form
  5. Benefit Fund Direct Deposit 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. Express Scripts Medicare Formulary List
  13. Health & Welfare Federal Acts & Guidelines Notice
  14. HRA Claim Form
  15. Maiden Name Form
  16. Notice of COBRA Rights
  17. Patient First Physical Exam Authorization Form
  18. Spouse Employment Verification Form
  19. Summary of Benefits and Coverage 2022 - Class I
  20. Summary of Benefits and Coverage 2022 - Class II

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_NJ (2023)
  2. Blue Medicare Advantage Plan - Evidence of Coverage_PA (2023)
  3. Express Scripts Medicare Formulary List

Merger

  1. CBF Participant Merger Notification

Retirement Funds

  1. 2022 COB-Retired
  2. Beneficiary Designation Form
  3. Benefit Fund Direct Deposit Form
  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)