Active Health Plan Forms

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.

Claim Form



  • HIPAA Privacy Notice — The Southern California IBEW-NECA Health Plan may use the limited quantity of private health information available, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), for purposes of making or obtaining payment for your care and conducting health care operations.
  • Life and Accidental Death & Dismemberment Insurance/Beneficiary Designation Form (Active Only) — Use this form to designate beneficiary(ies) for Life and Accidental Death and Dismemberment Insurance.
  • Change of Address — Use this form to change your address. Be sure to fill it out completely and return it to the Trust Office. (English Version)
  • Forma Para Solicitar Cambio De Dirección (En Español) — Use esta forma para hacer un cambio de dirección postal.  Asegúrese de completar todos los espacios en la forma, y de enviar la misma a la oficina del Trust Funds.
  • Workers Compensation form (Active Only) — Complete this form for consideration of benefits.
  • HIPAA Participant Authorization Form — Use this form to instruct the Fund Office to communicate with you at an alternate address regarding your eligibility, carrier changes, etc.

Health Reimbursement Arrangement

Legally Required

Notice of Creditable Coverage

Plan Documents (en Español)

Plan Documents (in English)

  • Summary Plan Description (Restated as of 9/1/2017) — For Eligible Active Participants and Their Eligible Dependents.
  • Amendment 1 — Amendment No. 1 to the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Restated As Of September 1, 2017.
  • Amendment 2 — Amendment No. 2 to the Summary Plan Description of the Southern California IBEW-NECA Health Trust Fund Restated As Of September 1, 2017.

Summary of Benefits and Coverage (SBC)

Video Library

  • Review of Plan Eligibility — The Fund Office has prepared a video to understand how to gain and maintain eligibility in the SC IBEW-NECA Health Plan. Take a brief tour and review the video. The video is not a substitute for the Summary Plan Description. Prior to filing any application for benefits, you should thoroughly review the Summary Plan Description (SPD).