These printable forms are in PDF (Portable Document) format.
To read and print them, you need the free Adobe Reader (which is probably already installed in your system). If you do need to install it, click below.
NEW: Complete & Print Forms - You can complete most of the forms listed below right on your computer before you print.
Simply click on the form and type in the appropriate information.
Then print the completed form, sign and mail it to the Plan Office.
Forms with this feature are indicated below with the "COMPLETE & PRINT " notation.
- Privacy Notice - The privacy of your personal health information has always been of paramount importance to the
Plan. Recent federal regulations require that the Plan provide all participants with a written notice
of its privacy practices. This notice can be viewed here.
- Performer Information Form - COMPLETE & PRINT
The "Performer Information Form" is the primary source for demographic information for each participant.
- New Dependent Form - COMPLETE & PRINT
This form is used to add new dependents. You as the Participant must be covered in order for coverage to be extended to your dependents.
- Designation of Beneficiary for Life Insurance - COMPLETE & PRINT
This form designates your beneficiaries. Please refer to the instructions while filling this form out.
- Annual Summary of Earnings - This is a record of all session and residual earnings reported on your behalf to the Pension and Health Plans during the calendar year. It also reflects your total Pension Credits and accrued benefits under the Pension Plan.
- Authorization For Release of Health Information - This form is used when a participant wishes to authorize that their health information be disclosed to a particular person or organization.
- Notice of Creditable Coverage - This Notice contains important information about the prescription drug coverage with the SAG-Producers Health Plan and the Medicare Prescription Drug Plan (PDP) coverage.
|
HEALTH PLAN PREMIUM
|
- Premium Payment Rules For Earned and Earned Inactive Coverage - All Earned and Earned Inactive Participants are required to pay a premium for Health Plan coverage. This document outlines all of the current rules concerning premium payment.
- Senior Performer Or Extended Spousal Rule Sheet - All participants who meet the requirements for Senior Performers or Extended Spousal coverage are required to pay a premium as of January 1, 2010. One premium covers you and all of your eligible dependents.
- Earned Premium Payment Chart - This chart gives a handy comparison of the four methods available to pay premiums.
- Earned Premium Auto Debit Plan Application - COMPLETE & PRINT
The Auto Debit Plan deducts your quarterly premium automatically on a recurring basis each quarter from a checking or savings account. Payments are deducted on the 25th of the month prior to the due date.
- Senior Performers Auto Debit Plan Enrollment Form - COMPLETE & PRINT
Use Auto Debit to ensure that your Senior Performers premium is paid on time each month. Payments are deducted on the 25th of the month prior to the due date.
|
BROCHURES
|
- Dental Benefits Brochure - This two-page brochure gives a brief description of the dental benefits offered through the Health Plan. While it's not intended as a substitute for the Summary Plan Description, it is a handy reference.
- Vision Benefits Brochure - This two-page brochure gives a brief description of the vision benefits offered through the Health Plan. While it's not intended as a substitute for the Summary Plan Description, it is a handy reference.
|
CLAIM FORMS
|
- Medical Claim Form - COMPLETE & PRINT
Participants should use this form when submitting claims for medical care to the Plan Office.
- Delta Dental Claim Form - COMPLETE & PRINT
You only need this form if you are treated by a dentist who is not a member of Delta Dental.
- Delta Dental Claim Form Instructions - The are the instructions for completion of the Delta Dental claim form.
- Medco Rx Claim Forms - This is the claim form for reimbursement of prescription drug claims.
- Medco Home Delivery Pharmacy Service Order Form - This form is used when ordering prescription drugs through the
Home Delivery Service.
- Mental Health / Substance Abuse Treatment Claim Form - COMPLETE & PRINT
Please read the directions for completion of this form.
- Health Insurance Claim Form - COMPLETE & PRINT
This form is typically filled out and submitted by Health Care Providers.
|
DISABILITY
|
- Attending Physicians Statement of Disability - Your physician must complete this form for you to receive the total disability extension to eligibility.
|
SELF-PAY INFORMATION AND FORMS EFFECTIVE 2012
|
- Self-pay Program Summary - This summary describes your rights and responsibilities for enrollment and participation in the Self-Pay Program.
- Self-Pay Tier FAQs - Frequently asked questions about the Self-Pay tier structure, effective January 1, 2012.
- Self-pay Payment Options - This chart gives an overview of each of the options available for self-pay.
- Self-Pay Auto Debit Plan Application - COMPLETE & PRINT
The Self-Pay Checking and Savings Auto Debit Plan deducts your monthly premium automatically on a recurring basis each month from a checking or savings account. Payments are deducted on the 25th of the month prior to the due date.
- New York State COBRA Assistance Program Application - COMPLETE & PRINT
Complete this application to apply for the NY COBRA Assistance Program, which will assist eligible entertainment industry employees with the payment of their COBRA continuation insurance premiums.
- Self-pay Enrollment Form - Plan I - COMPLETE & PRINT
This form is for participants and their qualified dependents if the participant was covered under Plan I.
- Self-pay Enrollment Form - Plan II and 3 or More Years of Coverage - Includes Dental - COMPLETE & PRINT
This form is for participants and their qualified dependents if the participant was covered under Plan II and had three or more years of eligibility under the Health Plan.
- Self-pay Enrollment Form - Plan II and Less Than 3 Years of Coverage - Medical Only - COMPLETE & PRINT
This form is for participants and their qualified dependents if the participant was covered under Plan II and had less than three years of eligibility under the Health Plan.
- Self-pay Enrollment Form - Plan I - Loss of Dependent Status - COMPLETE & PRINT
This form is for qualified dependents who lose their dependent status due to the death of a
participant, divorce from a participant, dissolution of a domestic partner relationship with a
participant, or loss of “child” status as defined by the Plan if the participant was covered under Plan I.
- Self-pay Enrollment Form - Plan II - Loss of Dependent Status and 3 or More Years of Coverage - Includes Dental - COMPLETE & PRINT
This form is for qualified dependents who lose their dependent status due to the death of a
participant, divorce from a participant, dissolution of a domestic partner relationship with a
participant, or loss of “child” status as defined by the Plan if the participant was covered under Plan II and had three or more years of eligibility under the Health Plan.
- Self-pay Enrollment Form - Plan II - Loss of Dependent Status and Less Than 3 Years of Coverage - Medical Only - COMPLETE & PRINT
This form is for qualified dependents who lose their dependent status due to the death of a
participant, divorce from a participant, dissolution of a domestic partner relationship with a
participant, or loss of “child” status as defined by the Plan if the participant was covered under Plan II and had less than three years of eligibility under the Health Plan.
- Self-pay Enrollment Form - Plan I - Early Retirement and Disability Pensioners - COMPLETE & PRINT
This form is for Early Retirement and Disability Pensioners and their qualified dependents if the participant was covered under Plan I.
- Self-pay Enrollment Form - Plan II - Early Retirement and Disability Pensioners - COMPLETE & PRINT
This form is for Early Retirement and Disability Pensioners and their qualified dependents if the participant was covered under Plan II.
|
DOMESTIC PARTNERSHIP
|
|
|
| | | | | |
