Forms
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Health & Welfare Forms
Add/Delete Dependents Form
Use this form when you need to either add or remove dependents from the Plasterers 66 plan.
Health Plan Enrollment Form
This form should be used to enroll in the Plasterers 66 plan once you become eligible for coverage.
Kaiser Enrollment/Change Form
Use this form to enroll in Kaiser or to add or delete dependents in Kaiser.
Health Net Member Enrollment and Change Form
Use this form to enroll in the Health Net HMO plan or to add or delete dependents in the Health Net HMO plan.
Delta Dental Enrollment Form
Use this form to enroll in the Delta Dental plan.
Request for Continued Coverage for Incapacitated Child
This form is required to be completed every two years if you have a dependent child who has reached the limiting age but continues to have coverage due to a mental or physical handicap.
COBRA Election Form
This form is used to initiate continuous health coverage should you experience a COBRA qualifying event.
Retiree Benefits Application
Retirees should use this form to apply for Retiree Health and Welfare coverage.
Change of Beneficiary – Life Insurance
Use this form to change the beneficiary for your Life Insurance benefits.
Points Account: Premium Payment/Reimbursement Request
Use this form to use our Points Account balance to pay your monthly retiree or COBRA premium or to request a reimbursement from your Points Account balance.
Pension Forms
Defined Contribution Pension Application
Use this form to apply for your Defined Contribution Pension benefits if you are a participant in the
Plasterers Local 66 Supplemental Pension Plan.
Defined Contribution Plan Eligible Rollover Distribution
This is a notice and election form for participants, surviving spouses and alternate payees regarding eligible rollover distributions from the
Plasterers Local 66 Supplemental Pension Plan.
Defined Contribution Plan Eligible Rollover Distribution for non-Spouse Beneficiaries
This is a notice and election form for non-spouse beneficiaries regarding eligible rollover distributions from the
Plasterers Local 66 Supplemental Plan.
Your Rollover Options for the Defined Contribution Plan- IRS Tax Notice 2010
This is a notice regarding plan payments and rollovers for the
Plasterers Local 66 Supplemental Pension Plan.
Right to Defer Notice
This notice describes the provisions of the
Plasterers Local 66 Supplemental Pension Plan that may affect your decision to defer distribution of your benefit
Defined Contribution Pension Hardship Withdrawal Application & Election Form
Use this form to apply for a hardship withdrawal from the
Plasterers Local 66 Supplemental Pension Plan and to make a withholding election if you qualify for this withdrawal.
Authorization for Automatic Deduction for Health & Welfare Plan
Use this form to authorize an automatic distribution from your hardship-based pension benefit payment directly to the Health & Welfare Trust for up to three consecutive months of health & welfare coverage.
Defined Contribution Plan Change of Beneficiary Designation Form
Use this form to change your beneficiary for death benefits under the Plasterers Local 66 Supplemental Pension Plan. Please note: if you are married, you must have your spouse's written and notarized approval to change your beneficiary to someone other than your spouse.
Defined Benefit Plan Eligible Rollover Distribution
This is a notice and election form for participants, surviving spouses and alternate payees regarding eligible rollover distributions from the
Northern California Plastering Industry Pension Plan.
Defined Benefit Plan Eligible Rollover Distribution for non-Spouse Beneficiaries
This is a notice and election form for non-spouse beneficiaries regarding eligible rollover distributions from the
Northern California Plastering Industry Pension Plan.
Your Rollover Options for the Defined Benefit Plan- IRS Tax Notice 2010
This is a notice regarding plan payments and rollovers for the
Northern California Plastering Industry Pension Plan.
Defined Benefit Pension Application Request
As you near retirement, you will want information about your retirement options. Use this form to request pre-retirement and benefit estimate information.
Defined Benefit Plan Change of Beneficiary Designation Form
Use this form to change your beneficiary for death benefits under the Northern California Plastering Industry Pension Plan. Please note: if you are married, you must have your spouse's written and notarized approval to change your beneficiary to someone other than your spouse.
Electronic Funds Transfer Form
Use this form if you wish to have your monthly pension payment deposited directly into your checking or savings account.
Tax Withholding Form
Payments from your pension plan are subject to federal and state income tax withholding. This form allows you to declare your tax withholding status.
Vacation Forms
Vacation Fund Change of Beneficiary Designation Form
Use this form to change your beneficiary for death benefits under the vacation fund.
General Use Forms
Change of Information Form
Use this form to change your address or other information you have on file at Allied Administrators