On This Page:

• Enrollment
• Self Contribution Coverage
• COBRA
• Retiree Health Plan
• Claims

Complete & Print Forms - You can complete most of the forms listed below right on your computer before you print. Simply click on a field in the form and type in the appropriate information. Then print the completed form, sign and mail it to the Trust Office. These printable forms are in PDF format. To read and print them, you need the free Adobe Reader (which is probably already installed in your system). Click here if you do not have Adobe Reader installed on your system.

Enrollment

• Enrollment Form (Western and Central Washington Benefit Package) — Your fringe benefit package includes a health and security plan, life insurance benefits, two pension plans, and a vacation plan. Before you and your eligible dependents can participate in these plans, you must complete this form in its entirety and return it to the Trust Office.

  If you are adding a Domestic Partner, please write or type "Domestic Partner" under the Relationship heading. If you are enrolling a dependent child of your Domestic Partner, please write or type "Partner, Dependent" under the Relationship heading.

• Enrollment Form (Eastern Washington, Idaho, Montana, Wyoming Benefit Package) — If you were previously covered under the Carpenters-Employers Health and Security Plan of Washington-Idaho, you must have an updated Enrollment Form on file at the Trust Office for your claims to be paid.
• Enrollment Form - Surviving Spouse — If you are the surviving spouse of a deceased participant, use this form to enroll for continuing health coverage under the Plan.
• Change of Address — This is the Change of Address notice. Please fill out this form and submit it to the Trust Office if your address has changed.
• Authorization To Transfer Fringe Benefit Contributions — Participants in the Trust may use this form to authorize the transfer of fringe benefit contributions.
• Authorization To Transfer Fringe Benefit Contributions - Health and Security Contributions Only — Participants in the Trust may use this form to authorize the transfer of Health and Security fringe benefit contributions.
• Authorization To Transfer Fringe Benefit Contributions - Pension Contributions Only — Participants in the Trust may use this form to authorize the transfer of Pension fringe benefit contributions.
• Adult Child Insurance Questionnaire — As part of the Patient Protection and Affordable Care Act, most children are eligible under the Carpenters Health and Security Plan of Western Washington through age 25.
• Child Enrollee Questionnaire — This Child Enrollee Questionnaire is used to establish basic facts about the child being enrolled in the plan.
• Student Questionnaire — Please answer the questions on this form and provide proof of full-time student status for applicable quarters. This will be used to determine the student's eligibility under the plan.
• Summer Student Questionnaire — Please answer the questions on this form and provide proof of full-time student status for applicable quarters.
• Affidavit of Domestic Partnership — Complete this form and have it notarized. Be sure to send the documentation of joint financial responsibility requested on the Affidavit.
• Domestic Partner Coverage - Affidavit of Dependent Status — Read the Explanation of Tax Issues Associated with Coverage for Domestic Partner. If you are seeking to establish that your Domestic Partner is a dependent for federal tax purposes, then complete the Affidavit of Dependent Status and have it notarized.

  If you are not seeking to establish dependency for tax purposes, you do not need to complete the form. The Trust will automatically assume that the value of health insurance for your Domestic Partner is taxable income, in accordance with IRS regulations. The Trust Office will send you an invoice for your first withholding payment and monthly remittance notices thereafter.

Self Contribution Coverage

• Self Contribution Notice — This letter provides eligibility requirements, cost, and duration of coverage information for Self-Contribution Coverage.
• Self Contribution Application (Western and Central Washington) — Fill out this form to apply for Self-Contribution Coverage.
• Self Contribution Application (Eastern Washington, Idaho, Montan, Wyoming) — Fill out this form to apply for Self-Contribution Coverage.
• Self Contribution Extension Application — Use this form to apply for an extension of Self-Contribution Coverage.
• Self Contribution Certificate of Disability — Use this form if you are applying for Self-Contribution Coverage because of a temporary disability.

COBRA

• General Notice of COBRA Continuation Coverage Rights — Contains information of your COBRA Continuation Coverage rights.
• COBRA Application - 18 Month Qualifying Event (Western and Central Washington) — If you qualify and would like to participate in COBRA Continuation Coverage, you must complete this application and return it to the Trust Office.
• COBRA Application - 18 Month Qualifying Event (Eastern Washington, Idaho, Montana, Wyoming) — If you qualify and would like to participate in COBRA Continuation Coverage, you must complete this application and return it to the Trust Office.
• COBRA Application - 36 Month Qualifying Event (Western and Central Washington) — If you qualify and would like to participate in COBRA Continuation Coverage, you must complete this application and return in to the Trust Office.
• COBRA Application - 36 Month Qualifying Event (Eastern Washington, Idaho, Montana, Wyoming) — If you qualify and would like to participate in COBRA Continuation Coverage, you must complete this application and return in to the Trust Office.
• COBRA Application - 11 Month Qualifying Event (Western and Central Washington) — As described in the General Notice of COBRA Continuation Coverage Rights, in the event of a reduction in hours of employment or termination of employment, COBRA Continuation Coverage can be extended if a qualified beneficiary is determined disabled by the SSA. Use this form to apply for an extension.
• COBRA Application - 11 Month Qualifying Event (Eastern Washington, Idaho, Montana, Wyoming) — As described in the General Notice of COBRA Continuation Coverage Rights, in the event of a reduction in hours of employment or termination of employment, COBRA Continuation Coverage can be extended if a qualified beneficiary is determined disabled by the SSA. Use this form to apply for an extension.

Retiree Health Plan

• Retiree Health Plan Application (Western and Central Washington) — If you qualify and would like to participate in the Carpenters Health and Security Plan of Western Washington – For Retired Carpenters (the Retiree Health Plan), you must complete this application and return it to the Trust Office.
• Retiree Health Plan Application (Eastern Washington, Idaho, Montana, Wyoming) — If you qualify and would like to participate in the Carpenters Health and Security Plan of Western Washington – For Retired Carpenters (the Retiree Health Plan), you must complete this application and return it to the Trust Office.
• Retiree Health Reimbursement Account Application — If you are eligible for the Retiree Health Plan and would like to pay a portion of your monthly premium from your Retiree Health Reimbursement Account, please complete this application and return it to the Trust Office.
• Notice to Decline Coverage Agreement — If you have been offered coverage under the Carpenters Health and Security Plan - For Retired Carpenters, and wish to decline the offer, fill out this form and return it to the Trust Office.

Claims

• Dental Fee Schedule (Western and Central Washington Benefit Package) — This is a list of some of the more frequently covered procedures. Fees for other procedures are available from the Trust Office.
• Dental Fee Schedule (Eastern Washington, Idaho, Montana, Wyoming Benefit Package) — If you were previously covered under the Carpenters-Employers Health and Security Plan of Washington-Idaho, please use this Dental Fee Schedule.
• Request for Life Benefit — Use this form to submit a request for Life Benefit. Please include a certified copy of Death Certificate and mail the completed request to the Claims Department.
• Time Loss Application - Employed Carpenters — Use this form to apply for Time Loss Benefits. The first section must be filled out by the Carpenter, and the second by the Carpenter's attending physician. Mail the completed form to the Trust Office.
• Time Loss Benefits Update - Employed Carpenters — Use this form to apply for Time Loss Benefits Update. The first section must be filled out by the Carpenter, and the second by the Carpenter's attending physician. Mail the completed form to the Trust Office.
• Time Loss Benefits For Mental Health Disability - Employed Carpenters — Use this form to apply for Time Loss Benefits for Mental Health Disability. The first section must be filled out by the Carpenter, and the second by the Carpenter's attending physician. Mail the completed form to the Trust Office.
• Certificate of Medical Necessity — Use this form to certify that equipment is medically necessary for treatment of participant's illness or injury.
• Mental Health Evaluation Report — This form is used report a participant's mental health evaluation.
• Prescription Drug Reimbursement Form — This form is used to apply for reimbursement of drugs for a participant eligible for drug benefits.
• Medco By Mail Order Form — This form is used to order medications from Medco By Mail.
• Medco By Fax Order Form — This form is used to order medications from Medco By Fax.
• Health, Allergy & Medication Questionnaire — Fill out this questionnaire to help the Trust provide your pharmacy benefit services including, for example, filling prescriptions.
• Personal Injury Questionnaire — This questionnaire is used by the Trust to document personal injuries.
• Injury Questionnaire — This questionnaire is used by the Trust to document accidental injuries.
• Motor Vehicle Accident Report — This questionnaire is used by the Trust to document motor vehicle accident.
• Reimbursement Agreement - Work-Related Injury or Illness — This Agreement is between the Board of Trustees of the Carpenters Health and Security Trust of Western Washington ("Trust") and the undersigned patient.
• Reimbursement Agreement - Third-Party or Insurer — Reimbursement Agreement when recovery is obtained against a third party or insurer.