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Plan Documents & Forms

Plan Documents & Amendments

Summary Plan Description (Plans 5, 6, 6A, 11A, 11B)
Summary & Supplemental Information Insert (Plan 5)
Summary & Supplemental Information Insert (Plans 6 & 6A)
Summary & Supplemental Information Insert (Plans 11A & 11B)

Plan Document / Summary Plan Description (Plan 7)
Summary & Supplemental Information Insert (Plan 7)

Kaiser Evidence of Coverage

Summary of Material Modifications

Aug 2022 – Plan Changes Regarding the No Surprises Act

Forms

Application for Retiree Benefits
Change of Address
COBRA Application
Dual Coverage Questionnaire
Enrollment
HIPAA Release of Information
Kaiser Withdrawal
Short-Term Disability Form
VOYA Life Insurance Claim
Third Party Liability Form

Notices

Notice of Creditable Coverage
2022 Creditable Coverage Disclosure

Summary Annual Report
2021 SAR

Other Notices
COBRA Notice
Notice of Privacy Practices
Women’s Health & Cancer Rights Notice

Reports

Summary of Benefits & Coverage (SBC)

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Fillable PDF Forms

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Website Disclaimer

This website provides a summary of the benefits available through the Fund and does not contain all information that may apply to your individual situation.  Where this page deviates from the information provided in the official Plan Document(s), the official Plan Document(s) terms shall prevail.

Plan Administrator / Trust Fund Office

Health Services & Benefit Administrators

Office Hours
Monday - Friday
8:30 a.m. to 5:00 p.m. (PST)

4160 Dublin Boulevard, Suite 100
Dublin, CA 94568-7756
Phone (800) 654-1824

Links

Teamsters Local 315

Teamsters Local 665

Teamsters Local 853

Teamsters Local 890

Teamsters Local 2785

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