Cement Masons Picture

CEMENT MASONS TRUST FUNDS
FOR NORTHERN CALIFORNIA


Summary Annual Report
Summary of Benefits Pamphlet
Health & Welfare Forms
HIPAA & PHI Forms

Vacation-Holiday Forms Pension Forms
Employer Forms
Miscellaneous Forms
Comparison Forms

Health & Welfare Forms

The following is a list of Health and Welfare plan forms and informational publications that can be requested from the Fund Office.

Some of the plan documents may be available for online viewing in the PDF file format. Adobe's Acrobat Reader® is required.

If you do not have Adobe’s Acrobat Reader® installed on your computer, click here to go to the Adobe website to download and install the most recent version.

If you would like the document mailed to you:

  1. Select the checkbox next to the document’s name (you can select as many different documents as you like).
  2. Once your selections are made, scroll down this page and comlete your personal information.
  3. When ready to send your request, click the Submit button to automatically send the Email request to our Customer Service section.
General Health & Welfare Forms
Document
Description
In-Mail Request
Update marital status, add a new spouse or dependent child, designate a beneficiary and update mailing address.
Initially choose, or change your current, hospital-medical plan option.
Initially choose, or change your current, hospital-medical plan option.
Update your mailing address.
Application for extended eligibility due to absence from covered employment because of a disability.
Start or continue benefit coverage for a handicapped, dependent child.
Establish dependent coverage for a foster child or stepchild.
Application form to extend benefit coverage for a dependent child who is over 19 years of age and a student at an accredited educational institution.
Authorization for the Trust Funds to electronically send your Vacation benefit checks to your designated financial institution. Faster, convenient and more secure than mailing checks to an address.
Death Notification & Benefit Application Forms
Document
Description
In-Mail Request
Notify the Fund Office of the participant’s (Cement Mason’s) death (submitted by the spouse or beneficiary)
Notify the Fund Office of the death of a spouse or dependent child (form submitted by the participant)
Form to enroll eligible Beneficiaries/Dependents, of a Deceased Participant/Pensioner, in order to continue applicable Health and Welfare Plan benefits.
 Dental Benefit Plan Information
Document
Description
In-Mail Request
 Active Dental Plan Pamphlet
Description of dental benefits for Active Cement Masons and their dependents.
 Retired Dental Plan Pamphlet
Description of dental benefits for Retired Cement Masons and their dependents.
 DeltaPreferred Option (DPO)
Optional Dental Plan
Pamphlet describing a new optional dental benefits program for Active and Retired Cement Masons and their dependents.
Application form describing a new optional dental benefits program for Active and Retired Cement Masons and their dependents.
  Pharmacy Benefits Plan Information
Document
Description
In-Mail Request
Pamphlet, with enrollment form, describing a prescriptions-by-mail service offered as part of the Pharmacy benefit.
Complete and return this form when you have purchased a covered, prescribed prescription drug at retail cost and are seeking reimbursement.
  Vision Benefits Plan Information
Document
Description
In-Mail Request
Description of vision benefits for Cement Masons and their dependents.

   Miscellaneous Benefits & Trust Funds Information

Document
Description
In-Mail Request
 The Cement Mixer Quarterly Newsletter
News and information about your benefits, Trust Funds administration and a quarterly "Calendar of Events".
 The Benefit Bulletin Monthly Newsletter
A monthly informational bulletin for our valued participants –assisting you in understanding your benefits.
Directory of hospitals, physicians, ambulance services, ambulatory surgery centers, mental health facilities, hospice providers, home health agencies, home infusion therapy providers, laboratories, medical products/service providers, skilled nursing facilities, dialysis centers and ancillary medical providers participating in the Blue Cross® Prudent Buyer Plan PPO network, which is used to provide hospital-medical benefits to participants covered under the Trust Fund's Managed Health Care Plan.


Personal Information
(
* Indicates a required field)

Name*
 
Health Plan ID
 
Address 1*
 
Address 2
 
City*
 
State/Province*
 
ZIP/Postal Code*
 
Email Address
 
Telephone Number
 
TeleFAX Number
 

 

Copyright © 2003, Northern California Cement Masons Funds Administration, Inc.; All Rights Reserved.
(Derechos Reservados Propiedad Literaria, © 2003)