Fillable NORTHERN CALIFORNIA CARPENTER FUNDS ENROLLMENT FORM Directions: Complete (Carpenter Funds Administrative Office)

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NORTHERN CALIFORNIA CARPENTER FUNDS ENROLLMENT FORM Directions: Complete (Carpenter Funds Administrative Office)

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NORTHERN CALIFORNIA CARPENTER FUNDS ENROLLMENT FORM
P.O. BOX 2380, OAKLAND, CALIFORNIA 94614 · TELEPHONE (510) 633-0333 (888) 547-2054
benefitservices@carpenterfunds.com Fax: (510) 633-0215
Page 1 of 4
Enrollment Form 7/2019 opeiu 29 afl-cio (125)
Directions: Complete this form to initially enroll in the Plans administered by the Carpenter Funds Administrative Office or
to update your existing record.
Are you: A New Employee? OR Updating Your Record?
PARTICIPANT INFORMATION
Social Security Number,
UBC# or CFAO ID#
Date of Birth
(MONTH/DAY/YEAR)
Name
(Last) (First) (MI)
Address
Address (Line 2)
Phone Number
City
State
Zip
Email Address for the Receipt of Mandatory Disclosures (Voluntary)
*
Sex Male Female
Would you like us to update your contact information for all records of the Carpenters Union and Apprentice-
ship Training Committee? Yes No
Current or Most Recent Employer
Date Joined
Skill Class
Are you enrolling as a beneficiary of a deceased participant? Yes No
If Yes, please provide deceased participant’s Social Security Number:
LANGUAGE OPTION
Would you like to receive Fund correspondence in Spanish? Yes No
HEALTH PLAN SELECTION
Active Participant:
Please check only one option below.
Retired Participant:
Please check only one option below.
Indemnity Medical Plan
(Coordination of Benefits will apply)
Indemnity Medical Plan
Kaiser Permanente
(Group Number: 26, 9068, 9076 or 35684)
Kaiser Permanente
(Group Number: 26-30)
International Benefit Option
*
Providing your email address for the receipt of mandatory disclosures is voluntary. If you provide your email address, mandatory
disclosures will be sent via email. See “Electronic Delivery of Plan Correspondence” on Page 4 for more information about your rights
and responsibilities.
To Update your Records: Complete each page of the form, print it, sign it and return it via email, fax or mail.
Reset Form
NORTHERN CALIFORNIA CARPENTER FUNDS ENROLLMENT FORM
P.O. BOX 2380, OAKLAND, CALIFORNIA 94614 · TELEPHONE (510) 633-0333 (888) 547-2054
benefitservices@carpenterfunds.com Fax: (510) 633-0215
Page 2 of 4
Enrollment Form 7/2019 opeiu 29 afl-cio (125)
Participant’s Name
Participant’s SSN, CFAO ID or UBC#
MARITAL STATUS
Single
Married
Date of Marriage ____________________
Separated
Date of Separation ___________________
Divorced
Date of Dissolution ___________________
Former Spouse’s Name ________________________
Widowed
DEPENDENTS
When adding or removing a dependent, Certified Documentation is Required as follows:
• Adding a Spouse: Provide a legible photocopy of your Certified Marriage Certificate.
• Adding a Domestic Partner: Complete a Domestic Partner Packet.
• Removing a Spouse: Provide a copy of your final divorce decree including the filed Marital Settlement Agreement.
• Initial enrollment of your dependent children, stepchildren, or Domestic Partner’s children: Provide a legible photo-
copy of their Certified Birth Certificate.
• Adding Adopted children: Provide a copy of the adoption papers.
• Adding Children for whom you are the legal guardian: Provide a copy of the filed legal guardianship papers.
• If your dependent child is 19 or older and enrolled in Medicare you MUST submit a photocopy of your dependent’s
Medicare card.
Spouse or
Domestic Partner
First & Last Name
Date of Birth
Social Security Number
Sex: Male Female Is Dependent Medicare eligible? Yes No
Address (if different from Participant):
City
State
Zip
Dependent Child
First & Last Name
Date of Birth
Social Security Number
Sex: Male Female
Is Dependent Medicare eligible? Yes No
Address (if different from Participant):
City
State
Zip
Dependent Child
First & Last Name
Date of Birth
Social Security Number
Sex: Male Female
Is Dependent Medicare eligible? Yes No
Address (if different from Participant):
City
State
Zip
Dependent Child
First & Last Name
Date of Birth
Social Security Number
Sex: Male Female
Is Dependent Medicare eligible? Yes No
Address (if different from Participant):
City
State
Zip
If you have additional dependents to add, please include their information on a separate sheet.
Reset Form
NORTHERN CALIFORNIA CARPENTER FUNDS ENROLLMENT FORM
P.O. BOX 2380, OAKLAND, CALIFORNIA 94614 · TELEPHONE (510) 633-0333 (888) 547-2054
benefitservices@carpenterfunds.com Fax: (510) 633-0215
Page 3 of 4
Enrollment Form 7/2019 opeiu 29 afl-cio (125)
Participant’s Name
Participant’s SSN, CFAO ID or UBC#
BENEFICIARIES – Complete Section A OR B below. It is not necessary to complete both.
If additional space is needed to list all beneficiaries, please provide the information on an additional sheet.
Note: Plan rules dictate that unless certain criteria are met, your legal spouse will be considered your Beneficiary for benefits from the Carpenters
Annuity Trust Fund Trust Fund for Northern California, Carpenters Pension Trust Fund for Northern California, and Northern California Carpenters
401(k) Plan. If you are married and name a Beneficiary other than your Spouse below for your Pension, Annuity, and/or 401(k) it may be necessary
for your Spouse to complete additional paperwork to consent to that Beneficiary designation. For more information consult the Plan Rules and
Regulations or contact the Trust Fund Office at (888) 547-2054 or benefitservices@carpenterfunds.com.
Section A – Complete this section to name the same Beneficiary(ies) for all Funds you participate in.
Beneficiary’s Full Name(s)
Relationship
Date of Birth
Social Security Number
Address
City
State
Zip
Section B – Complete this section to name different beneficiary(ies) for the Funds you participate in.
Annuity
Fund
Full Name(s)
Relationship
Date of Birth
Social Security Number
Address
City
State
Zip
Pension
Fund
Full Name(s)
Relationship
Date of Birth
Social Security Number
Address
City
State
Zip
Health &
Welfare
Full Name(s)
Relationship
Date of Birth
Social Security Number
Address
City
State
Zip
Vaca-
tion/Sick
Leave
Fund
Full Name(s)
Relationship
Date of Birth
Social Security Number
Address
City
State
Zip
401(k)
Plan
Full Name(s)
Relationship
Date of Birth
Social Security Number
Address
City
State
Zip
If any of the Beneficiaries you have listed in Section A or B are minors, you must provide the following:
Name of Guardian (Must be someone other than yourself)
Guardian’s Address
City
State
Zip
Reset Form
NORTHERN CALIFORNIA CARPENTER FUNDS ENROLLMENT FORM
P.O. BOX 2380, OAKLAND, CALIFORNIA 94614 · TELEPHONE (510) 633-0333 (888) 547-2054
benefitservices@carpenterfunds.com Fax: (510) 633-0215
Page 4 of 4
Enrollment Form 7/2019 opeiu 29 afl-cio (125)
Participant’s Name
Participant’s SSN, CFAO ID or UBC#
PARTICIPANT’S SIGNATURE
I apply for health plan membership for the persons listed and agree that we shall abide by the provisions of the health maintenance organization
(HMO) service agreement or Indemnity Plan regulations whichever applies. I understand that all claims, including medical malpractice claims, which
arise because I or someone with a relationship to me, believe that some conduct in, or arising from my relationship with the HMO, HMO hospitals,
or the HMO’s medical group as a member or a patient, has caused any harm, must be submitted to binding arbitration instead of a court trial.
Kaiser Foundation Health Plan Arbitration Agreement:
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA
claims procedure regulation, and any other claims that cannot be subject to binding arbitration under governing law) any
dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health
Plan, Inc. (KFHP), any contracted health care providers, administrators, or other associated parties on the other hand, for
alleged violation of any duty arising out of or related to membership in KFHP, including any claim for medical or hospital
malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompe-
tently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal
theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as
applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept
the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage.
I hereby certify under penalty of perjury under the laws of the State of California, that the information given in this form is true, correct, and complete
to the best of my knowledge.
Signature Date
Electronic Delivery of Plan Correspondence: Electronic materials are emailed, typically in Portable Document Format (PDF), and are identical to the
paper versions you've been receiving. There is no charge for accepting materials online. You will need an internet connection and a computer with
an operating system capable of receiving, accessing and displaying and either printing or storing the electronic documents received.
You should have Adobe Reader to access PDF files. Learn more and download Adobe Reader directly from Adobe's website, www.adobe.com. Change
your email address at any time by contacting the Fund Office at benefitservices@carpenterfunds.com, (510) 633-0333, or Toll-Free (888) 547-2054.
The change must be in writing, with your signature.
Some example documents that may be sent electronically include: Summary Plan Descriptions, Notice of Plan changes, Explanation of Benefits,
Benefit and Claim Department letters, Prohibited Employment Committee letters, and Fund Trustee memos.
Your consent to electronic delivery of Plan documents is valid unless and until you withdraw your consent. You can withdraw your consent and reset
your preference to mail at any time by contacting the Fund Office at benefitservices@carpenterfunds.com, (510) 633-0333, or Toll-Free (888) 547-
2054. The change must be in writing, with your signature. While e-delivery may significantly reduce the amount of mail we send you, certain docu-
ments and service-related correspondence will continue to be sent via U.S. Mail. Additionally, you may request a paper copy of any documents
received electronically. Unless otherwise instructed, your email address will be shared with the Carpenters Union, Apprenticeship Training Commit-
tee and the Carpenters Trust Funds.
I hereby certify under penalty of perjury under the laws of the State of California, that the information given in this form is true, correct, and complete
to the best of my knowledge.
Signature
Date
Once you have completed this document, return it to:
Carpenter Funds Administrative Office of Northern California, Inc.
P.O. Box 2380, Oakland, California 94614
benefitservices@carpenterfunds.com
Fax: (510) 633-0215
Reset Form
To Update your Records: Complete each page of the form, print it, sign it and return it via email, fax or mail.
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NORTHERN CALIFORNIA CARPENTER FUNDS ENROLLMENT FORM Directions: Complete (Carpenter Funds Administrative Office)

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Completed 13 January 2021

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