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Documents and Forms

  • Resources
  • Documents and Forms



COBRA

  • Cobra Notice - Alt Plan
    This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.
  • Cobra Notice - Base Plan
    This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.
  • Cobra Notice - Single Alt Plan
    This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.
  • Notification of Qualifying Event
    To preserve your right to elect COBRA, you or your qualified beneficiary must complete this form to notify the Fund Office within 60 days of when your coverage would end due to legal separation, divorce, or your dependent child ceasing to have “dependent” status.

Conduit 401(k) Plan Documents

  • 401(k): PD-2021 Edition
    The information in this Plan Document explains the Fund’s rules and procedures for the Conduit 401(k) Plan.
  • 401(k): SPD-2021 Edition
    This Summary Plan Description (SPD) booklet provides a summary of the Conduit 401(k)Plan’s features; complete details are contained in the Plan document.
  • 401(k): Trust Agreement
    The Agreement and Declaration of Trust between the Union and the Association to create the Conduit 401(k) Fund and Plan.
  • 401(k): PD Amendment 1
    This amendment to the Conduit 401(k) Plan Document deals with the time of commencement of benefit payments and minimum distribution requirements.
  • 401(k): Trust Agreement Amendment 1
    This amendment to the 401(k) Trust Agreement deals with investments of trust assets.
  • Hardship Withdrawal Guidelines
    This form outlines the basic requirements and the required documentation for eligible reasons for a hardship withdrawal from your 401(k).
  • Special Tax Notice Regarding Plan Payments
    This notice describes the rollover rules that apply to payments from the Plan.

Conduit 401(k) Plan Forms

  • Age 59.5 Distribution Form
    The form to use to request withdrawal from the Conduit 401(k) Plan for Participants age 59 1/2.
  • Distribution Form
    The form to use to specify a distribution election for distribution from the Conduit 401(k) Plan to another plan or for payment to the Participant.
  • Enrollment Form
    The enrollment form to use to enroll in the Conduit 401(k) plan and to select investments.
  • Hardship Form
    The form to use to request a hardship withdrawal from the Conduit 401(k) Plan.
  • Minimum Distribution Form
    This form is used to select payment options for minimum distributions from the 401(k) Plan that are required under federal law for participants who are 5% owners and terminated participants who have attained the age of 73.
  • Rollover Into Plan Form
    The form to use to complete to roll over amounts from an eligible retirement plan to the Conduit 401(k) Plan.
  • Tax Withholding Election Form
    The form to use to indicate if you are subject to backup withholding because you failed to report all interest and dividends on your tax return.

Employee Assistance Program

  • TELUS Health FAQs
    Frequently Asked Questions about the Employee Assistance Program (EAP); a work-life/well-being resource that provides confidential consultations, information and resources, connections to community agencies and supports, and referrals to counseling.
  • TELUS Health Overview
    Overview of the Employee Assistance Program (EAP) that provides immediate and confidential help for any work, health or life concern.
  • TELUS Health Service Overview
    Examples of what issues the Employee Assistance Program (EAP) can assist with.
  • TELUS Health How To Use The EAP
    How to use the Employee Assistance Program (EAP), including contact information.

Employers

Fund Office

  • Nondiscrimination Notice Section 1557 ACA
    Nondiscrimination notice describing how the Fund Office complies with applicable Federal civil rights laws.
  • Privacy Policy
    This privacy policy describes how medical information may be used and disclosed and how to get access to that information.

HRA

  • Benny Card Terms & Conditions
    A copy of the Terms and Conditions document that is included in the envelope when a participant receives the Benny Card.
  • HRA Direct Deposit Form
    A form which allows HRA reimbursements to be deposited directly into your bank account, rather than receiving a paper check in the mail.
  • Direct Transfer Form
    A form to complete which will allow the Fund Office to directly transfer funds from your HRA account to pay for your COBRA or self payment, or your retiree premium; this eliminates the need to pay first, then get reimbursed from your HRA account later.
  • How to Use the HRA Mobile App
    A guide for how to setup and use the HRA mobile app, for submitting receipts and reimbursement requests.
  • HRA Benny Card Participant Guide
    A guide for HRA accounts which includes usage notes about HRA accounts as well as the Benny Card follow-up process (documents required, Benny Card suspensions, and 1099M notices).
  • HRA Eligible Expenses
    An explanation of what Eligible Medical Care Expenses are, as described by IRS Publication 502, as well as references to lists of eligible and ineligible expenses.
  • HRA Participant Portal User Guide
    An introduction and guide for the HRA participant web portal.
  • HRA Reimbursement Terms & Conditions
    A list of terms and conditions for claims submitted for reimbursement from your HRA account.
  • Health Reimbursement Arrangement (HRA) Account Claim for Reimbursement
    A paper claim form to request reimbursement from your HRA account. Note: the preferred method for submitting claims for reimbursement is by using the participant portal or mobile app - please contact Customer Service if you need assistance with these preferred methods.
  • Use the Mobile App to Change Your Password
    Instructions for changing your password on the HRA mobile app.
  • How to Login to the HRA Participant Portal
    Instructions for creating an account on the HRA participant web portal. This login information can also be used to login to the HRA mobile app.
  • How to Use Your Benny Card
    A detailed PowerPoint presentation about HRA accounts, including how and where to use the Benny Card, and what happens after the Benny Card is swiped.
  • View Account Activity

Newsletters

  • Newsletter: 2021 December
    Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with No Surprises Act updates, Cologuard testing, ABA Therapy, incoming reciprocity changes, donated hours, ground ambulance coverage, TeleHealth, and the EyeMed vision network.
  • Newsletter: 2021 July
    Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with benefit improvements, new vision network, out-of-network allowable charges, BCBS class action litigation, and HRA coverage improvements.
  • Newsletter: 2022 June
    Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with the Medicare Advantage Program, coverage for OTC COVID-19 tests, contribution rates, disability payments, and ABA speech and occupational therapy limits.
  • Newsletter: 2023 January
    Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with the Medicare Advantage program, the Employee Assitance Program , occlusal guard coverage, contribution rate and retiree premium changes, and COBRA rates.
  • Newsletter: 2023 July
    Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with contribution rates, non-grandfathered Plan status, and co-insurance rate changes, MedImpact, New BCBS network for Wisconsin members, and COVID-19 emergency end.
  • Pension Trust Fund PowerPoint Presentation

Pension Trust Fund Documents

Pension Trust Fund Forms

Retirees

Summary of Benefits and Coverages

Welfare Trust Fund Documents

Welfare Trust Fund Forms

  • Data Card
    The Data Card is the annual enrollment form that must be completed for claims to be processed. The Data Card can be completed on the MemberXG portal, or by completing and submitting this paper form to the Fund Office.
  • Appeal Form/Authorized Representative Form-Welfare Trust Fund
    This appeal form is used to request a review of an adverse benefit determination by the Welfare Trust Fund.
  • Authorized Representative Designation Form
    This form is used to appoint a personal or authorized representative to receive your personal health information.
  • Beneficiary Designation Form-Welfare Trust Fund
    This form is used to specify your beneficiary, or beneficiaries, for applicable benefits provided by the Welfare Trust Fund.
  • Continuity of Care Benefits Request and Release of Information Form
    The form to use to request Continuity of Care Benefits, to use when your in-network provider goes out-of-network; conditions apply.
  • Customer Service Consent (HIPAA Form)
    This form is used to give permission to the Fund Office to discuss your benefits with another entity.
  • Direct Transfer Form
    This form is used to give permission to the Fund Office to transfer funds directly from your Health Reimbursement Account (HRA) to make payments to the Fund Office for retiree premiums or COBRA/self-pay payments.
  • Hours Transfer Form
    This form is used to indicate that you wish to donate hours in your hour bank, under the Voluntary Hours Donation Program, to a fellow participant who is unable to work due to a catastrophic illness or injury of the Participant or the Participant's immediate family.
  • Member Accident Form
    The form that is used to report an incident related to an injury. Participants may receive multiple copies if there are many associated claims; this form only needs to be completed once per incident that caused the injury.
  • Other Liability Insurance Form
    The Fund Office may request that this form be completed if medical expenses due to an incident that causes an injury may be the responsibility of a third-party or other insurance.
  • Physician's Statement for Loss of Time from Work
    The form that a physician completes to document an incident or loss of time from work.
  • Specific Information Release
    This form is used to authorize the use or disclosure of your individually identifiable health information to specified providers or designated representatives.
  • Spousal and Dependent Insurance Form
    This form is to be completed by a spouse/dependent's employer, to specify if the spouse/dependent is offered insurance through their employer.
  • Subrogation Agreement and Loan Agreement
    This form is sent to claimants when the incident that caused a participant to incur medical expenses may be the responsibility of a third party.
  • Vision Benefit: EyeMed Reimbursement Form for Out-of-Network Claims
    The form to use to request reimbursement for out-of-network vision expenses; this form should be submitted to EyeMed, not the Fund Office.

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