INSURANCE COVERAGE
Congratulations! You have completed the required hours to become eligible to receive benefits under the Electrical Workers Benefit Trust Fund (EWBTF). The forms below must be completed within 60 days before any claims can be processed and paid.
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Please note - your insurance cards will not be activated and mailed until all documentation has been received.
PARTICIPANT ENROLLMENT FORM Required
This form will be used to activate your coverage. In addition to the Participant Enrollment Form, you must provide the documents listed below to add dependents:
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If you are married, you must submit a copy of your marriage certificate.
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If you have dependent children, including stepchildren, you must submit a copy of their birth certificate(s).
Please note - you only have 60 days to add dependents.
BENEFICIARY FORM Required
This form will determine who benefits will be payable to upon your death. If you are married this person must be your spouse UNLESS he/she signs the spousal waiver.
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Primary Beneficiary: An individual or organization who is first in line to receive benefits upon your death.
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Contingent Beneficiary: An individual who receives the benefits of an account if the primary beneficiary cannot or will not do so after your death.
HIPPA AUTHORIZATION FORM Optional
Completing this form is optional. If you are over the age of 18 and would like the Benefits Office to share your information with someone other than yourself, this form must be completed and returned.
ELIGIBILITY MATRIX
The chart below explains how EWBTF coverage works. Please note there is a difference between the work month and the eligibility month.
Initial: Applies to new Participants in the Plan. The Participant must work 700 hours within six consecutive months. Example: You meet the 700 hours anytime during the work month of January — your effective date will be March 1st.
Accelerated: Applies to new Participants in the Plan. The Qualifying Participant must work 160 hours within two consecutive months. Please contact the Fund Office for the requirements needed to qualify for Accelerated Initial Eligibility. Example: You meet the 160 hours anytime during the work month of January — your effective date will be March 1st.
Plan Change: Applies to Participants in the Plan who will be changing plan types (i.e. single coverage to fully family). The Qualifying Participant must work 160 hours within two consecutive months at the new contribution rate. Example: You meet the 160 hours anytime during the work month of January — your effective date will be March 1st.
Reinstatement of Benefits: If the Participant chooses NOT to continue their coverage via the Alternative SelfPayment Program or COBRA, their insurance will not reinstate until they have worked 160 hours within two consecutive months. Example: You meet the 160 hours anytime during the work month of January — your reinstatement date will be April 1st.
Continued: The participant must work at least 140 hours each month, or a combination of hours plus hours pulled from their "hour bank" to meet the 140 hours required for monthly continuation
Hour Bank: Once a Participant meets the initial eligibility requirement, they can begin adding to their hours bank each month. Hours worked over 140 will automatically be transferred into their hours bank that can be used later to help them meet the continuation rule. The maximum hours you can bank is 840 hours which is equivalent to 6 months of future coverage.
Termination of Benefits: If the Participant does not meet the continuing eligibility requirement listed in the above chart, they will receive information (mailed to the address on file in the Fund Office) stating their insurance coverage has terminated along with continuation of coverage options (Alternative Self-Payment Program or COBRA).