Documents and Forms

The Data Card is the annual enrollment form that must be completed for claims to be processed. The Data Card can be completed on the MemberXG portal, or by completing and submitting this paper form to the Fund Office.

This form is used to appoint a personal or authorized representative to receive your personal health information.

This form is used to specify your beneficiary, or beneficiaries, for applicable benefits provided by the Welfare Trust Fund.

The form to use to request Continuity of Care Benefits, to use when your in-network provider goes out-of-network; conditions apply.

This form is used to give permission to the Fund Office to discuss your benefits with another entity.

The form that is used to report an incident related to an injury for a dependent. Participants may receive multiple copies if there are many associated claims; this form only needs to be completed once per incident that caused the injury.

This form is used to give permission to the Fund Office to transfer funds directly from your Health Reimbursement Account (HRA) to make payments to the Fund Office for retiree premiums or COBRA/self-pay payments.

This form is used to indicate that you wish to donate hours in your hour bank, under the Voluntary Hours Donation Program, to a fellow participant who is unable to work due to a catastrophic illness or injury of the Participant or the Participant's immediate family.

The form that is used to report an incident related to an injury. Participants may receive multiple copies if there are many associated claims; this form only needs to be completed once per incident that caused the injury.

The Fund Office may request that this form be completed if medical expenses due to an incident that causes an injury may be the responsibility of a third-party or other insurance.

The form that a physician completes to document an incident or loss of time from work.

This form is used to authorize the use or disclosure of your individually identifiable health information to specified providers or designated representatives.

The form that is used to report an incident related to an injury for a spouse. Participants may receive multiple copies if there are many associated claims; this form only needs to be completed once per incident that caused the injury.

This form is to be completed by a spouse/dependent's employer, to specify if the spouse/dependent is offered insurance through their employer.

This form is sent to claimants when the incident that caused a participant to incur medical expenses may be the responsibility of a third party.

The form to use to request reimbursement for out-of-network vision expenses; this form should be submitted to EyeMed, not the Fund Office.

This appeal form is used to request a review of an adverse benefit determination by the Welfare Trust Fund.

A form for your Physician to complete and submit to the Wellness Power program, to earn the biometric Wellness reward.

A form for your Physician to complete and submit to the Wellness Power program, to earn the biometric Wellness reward for 2024.

Information about a website that provides information about the cost of procedures, how to find a doctor, and to request a member ID card.

A complete listing of current dental procedure codes and applicable benefit information for each individual procedure.

A graphical description of how to read your Explanation of Benefits (EOB).

How to view your Explanation of Benefits (EOB) on the member benefits website.

Five things to know about over-the-counter Hearing Aids.

Description and contact information for the EPIC Hearing Service Plan, which can provide savings on hearing aids and products.

Notice that the Plan Documents have been amended to establish the permitted and required uses and disclosures of protected health information.

This policy describes the protection of your health information.

Description of your rights and protections against surprise medical bills: when you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

The PaydHealth list of Select Drugs and Products; this list is updated quarterly.

The PaydHealth list of Select Drugs and Products; this list is updated quarterly.

The PaydHealth list of Select Drugs and Products; this list is updated quarterly.

NECA-IBEW Preventive Care guidelines

This document provides information about the Sword programs of Thrive (digital physical therapy) and Bloom (digital pelvic health for women).

A guide for how to use EyeMed's out-of-pocket cost estimator for vision benefits.

Resources available on the EyeMed website.

This flyer contains information about the types of support available from EyeMed regarding your vision benefits.

How to download and login to the EyeMed mobile app for vision benefits.

This flyer contains information about online shopping options for eyeglasses and contacts.

How to locate an in-network provider for EyeMed vision benefits.

This flyer contains information about special savings offers from EyeMed

This booklet is called a Summary Plan Description and Plan Document (SPD/PD). This document contains the complete features of the Base Plan, Alternative Plan, and the Supplemental Retirement Plan.

Your Color benefit brings you cancer risk experts. care coordinators, oncologists and primary care physicians to make sure you and your family stay ahead of cancer.

Complete your Cancer Risk Assessment with Color for a chance to win an Apple Watch.

The Schedules of Benefits for all Plans (Base, Alt, Retiree) summarizes the dollar benefits, quantity limits, deductibles, and co-insurance for each Plan.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding the EyeMed vision program.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding MDLive virtual visits.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding protections from surprise medical bills.

This Summary of Material Modifications (SMM) notifies participants of material changes, regarding the PaydHealth specialty drug program.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding the Wellness Power benefit.

This amendment to the Summary Plan Description/Plan Document deals with death/ADD benefits and weekly income benefits (disability), allowable charges, and telehealth.

This amendment to the Summary Plan Description/Plan Document deals with retiree eligibility, the donation hours program, teleheath, and reciprocity.

This amendment to the Summary Plan Description/Plan Document deals with the additions of definitions to the SPD/PD, protections from surprise medical bills, and other patient protections.

This amendment to the Summary Plan Description/Plan Document deals with changes to the Schedule of Benefits as related to Amendment 4.

This amendment to the Summary Plan Description/Plan Document deals with coverage of speech and occupational therapy, and COVID-19 testing.

This amendment to the Summary Plan Description/Plan Document deals with the Medicare advantage plan and retiree benefits.

This amendment to the Summary Plan Description/Plan Document deals with occlusal guards.

This amendment to the Summary Plan Description/Plan Documents deals with Donation of Hours.

This amendment to the Summary Plan Description/Plan Document deals with the deletion of grandfathered status.

This amendment to the Summary Plan Description/Plan Document deals with changes to covered medical expenses.

This amendment to the Summary Plan Description/Plan Document deals with HIPAA privacy and security rule compliance.

This amendment to the Summary Plan Description/Plan Document deals with initial eligibility and self-payments.

This amendment to the Summary Plan Description/Plan Document deals with deadline waiver requests.

This amendment to the Summary Plan Description/Plan Document deals with coverage for Narcan and the Sword Health Online Physical Therapy Benefit.

This amendment to the Summary Plan Description/Plan Document deals with the charges for special education, gene therapy, and pharmacological gene or cellular therapy is not a covered medical expense.

This amendment to the Plan Document deals with Covered Medications, Prescription Drug Benefit Exclusions, General Limitations and Exclusions, and other benefits.

Summary of the annual report for the NECA-IBEW Welfare Trust Fund. This report has been filed with the Employee Benefits Security Administration.

Summary of the annual report for the NECA-IBEW Welfare Trust Fund. This report has been filed with the Employee Benefits Security Administration.

Summary of the annual report for the NECA-IBEW Welfare Trust Fund. This report has been filed with the Employee Benefits Security Administration.

Summary of the annual report for the NECA-IBEW Welfare Trust Fund. This report has been filed with the Employee Benefits Security Administration.

Summary of the annual report for the NECA-IBEW Welfare Trust Fund. This report has been filed with the Employee Benefits Security Administration.

Summary of the annual report for the NECA-IBEW Welfare Trust Fund. This report has been filed with the Employee Benefits Security Administration.

Ways to earn 2025 incentives.

This wellness newsletter contains information about happiness and resilience awareness month, outdoor exercise, and an asparagus recipe.

List of Telligen Online Health Coaching Seminars for 2024.

This issue contains heart healthy exercises and recipes.

This document describes the process for downloading a Labcorp voucher for scheduling a screening and flu appointment.

This document describes the procedure to ordera home test kit from Labcorp.

This flyer contains information about exercises and recipes.

This flyer contains information about National Alzheimer's and Brain Awareness Month, Tai Chi, and recipe of the month.

This flyer contains information about the 2025 NECA-IBEW Wellness Program, including how it works, important dates, incentives, rewards, and biometric screenings.

This document describes the details for the new Wisconsin Blue Preferred POS Network for Wisconsin residents.

The form to use to fill out application for benefits of the Retiree Plan of the NECA-IBEW Welfare Trust Fund.

The form to use to complete authorization for automatic deposits/credits/debits for retiree plan payments to the NECA-IBEW Welfare Trust Fund.

The form to use to allow the Fund Office to directly transfer funds from your HRA account to pay for your COBRA or self payments, or your retiree premium. This eliminates the need for you to pay first, then get reimbursed from your HRA account later.

Notice of retiree medical benefits change to coverage provided by Humana Medicare Advantage Plan, implemented by Labor First.

Answers to frequently asked questions about Humana Medicare Advantage Plan, administered by Labor First.

The form to use to authorize the Fund to automatically reimburse your retiree premium from your HRA account.

The form to use to delay participation in the Retiree Plan if you have other medical coverage available through your spouse’s employer. Under the provisions of the In-and-Out Program, you and your spouse may postpone coverage, maintaining your eligibility to participate in this Retiree Plan, until you are no longer eligible for coverage under another plan.

Powerpoint presentation about the Supplemental Retirement Benefit Plan.

The form for retirees to use to complete if they are considering re-employment, to determine if pension benefits will be suspended if they return to work.

Benefit application and certification for pension benefits.

Benefit application and certification for pension benefits.

This form is required by all applicants for pension benefits, to indicate bargaining/non-bargaining work history.

Pension benefit application for an married participant; includes list of additional documents needed.

Pension benefit application for an unmarried participant; includes list of additional documents needed.

A document which explains the Qualified Joint & Survivor benefit options.

Notice of federal requirement to perform a maximum benefits test for the pension benefit, and form to complete information for the test to be conducted.

The form for retirees to use to notify the Fund Office if they return to work; regardless of number of hours worked or place of employment.

Notice of federal requirement to inform pensioners of their right to defer the distribution of their retirement benefit and the financial effect of such decision.

The form to use to file an appeal for an adverse benefit determination of the NECA-IBEW Pension Trust Fund.

IRS Tax Form W-4P

The form for retirees to use to notify the Fund Office when their benefits have previously been suspended, and now they will discontinue working and would like benefits to resume.

The form to use to indicate declaration to retire in order to receive a retirement distribution.

Example of how to draft a Qualified Domestic Relations Order (QDRO) for pension payments.

Description of temporary waiver of Pension Fund's Suspension of Benefits rules for 2024.

Form for waiver of joint and survivor benefit; federal law requires this form to be signed by both participant and spouse.

This booklet is called a Summary Plan Description (SPD) and is intended to provide a brief description of the Pension Trust Fund. Complete details of the Pension Trust Fund are contained in the Pension Trust Fund Plan Document.

This amendment to the Pension Trust Fund Pension Plan outlines the commencement date for pension payments.

This amendment to the Pension Trust Fund Pension Plan outlines the Waiver of Suspension of Benefits Rules.

This amendment to the Pension Trust Fund Pension Plan outlines the Exempted Employment.

This informational notice includes important funding information about the pension plan.

This informational notice includes important funding information about the pension plan.

This informational notice includes important funding information about the pension plan.

This informational notice includes important funding information about the pension plan.

This informational notice includes important funding information about the pension plan.

This informational notice includes important funding information about the pension plan.

This informational notice includes important funding information about the pension plan.

The information in this Plan Document explains the Fund’s rules and procedures and describes the benefits and coverage offered by the Pension Trust Fund.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding benefit multiplier and credited contributions.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding temporary waiver of suspension of benefit rules, suspension of benefits, and change to age required for minimum distributions.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding temporary waiver of suspension of benefit rules.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding non-credited contributions, disability benefit, and exempted employment, and plan trustees.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding restoration of non-credited contributions, disability benefit, QDRO, death benefits, and recalculation of benefits upon re-retirement.

This Summary of Material Modifications (SMM) notifies participants of material changes regarding non-credited contributions, suspension of benefits, and temporary waiver of suspension of benefit rules.

This Summary of Material Modifications (SMM) notifies participants about No Retirement Declarations for Participants Who Reach Age 70 ½, Exempted Employment: Inspectors, and New Money Rate.

The Agreement and Declaration of Trust between the Union and the Employer Trustees to create the Pension Trust Fund.

Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with No Surprises Act updates, Cologuard testing, ABA Therapy, incoming reciprocity changes, donated hours, ground ambulance coverage, TeleHealth, and the EyeMed vision network.

Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with benefit improvements, new vision network, out-of-network allowable charges, BCBS class action litigation, and HRA coverage improvements.

Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with the Medicare Advantage Program, coverage for OTC COVID-19 tests, contribution rates, disability payments, and ABA speech and occupational therapy limits.

Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with the Medicare Advantage program, the Employee Assitance Program , occlusal guard coverage, contribution rate and retiree premium changes, and COBRA rates.

Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with contribution rates, non-grandfathered Plan status, and co-insurance rate changes, MedImpact, New BCBS network for Wisconsin members, and COVID-19 emergency end.

Newsletters contain messages from the Trustees, benefit notes and changes, and important information about your privacy and keeping your contact information current. This newsletter also deals with new benefit programs, contribution rate changes, drug coverage exclusions, wellness program updates, the “Health Care Cost Estimator” tool, Out-of-Pocket limits, and retiree reminders.

This flyer contains information about Mental Health Awareness Month, yoga, and recipe of the month.

A copy of the Terms and Conditions document that is included in the envelope when a participant receives the Benny Card.

A guide for how to setup and use the HRA mobile app, for submitting receipts and reimbursement requests.

A guide for HRA accounts which includes usage notes about HRA accounts as well as the Benny Card follow-up process (documents required, Benny Card suspensions, and 1099M notices).

An explanation of what Eligible Medical Care Expenses are, as described by IRS Publication 502, as well as references to lists of eligible and ineligible expenses.

An introduction and guide for the HRA participant web portal.

A list of terms and conditions for claims submitted for reimbursement from your HRA account.

A paper claim form to request reimbursement from your HRA account. Note: the preferred method for submitting claims for reimbursement is by using the participant portal or mobile app - please contact Customer Service if you need assistance with these preferred methods.

Instructions for changing your password on the HRA mobile app.

Instructions for creating an account on the HRA participant web portal. This login information can also be used to login to the HRA mobile app.

A detailed PowerPoint presentation about HRA accounts, including how and where to use the Benny Card, and what happens after the Benny Card is swiped.

Nondiscrimination notice describing how the Fund Office complies with applicable Federal civil rights laws.

This privacy policy describes how medical information may be used and disclosed and how to get access to that information.

This document describes the contribution agreement for bargaining unit alumni employees for the Conduit 401(k) Plan.

The IBEW-NECA 401(k) Plan collection and payroll audit policy.

This document describes the contribution agreement for non-bargaining unit employees for the Conduit 401(k) Plan.

Participation agreement for the IBEW NECA Conduit 401(k) Plans that apply to non-bargaining unit employees and bargaining unit alumni employees.

This notice describes the employer's option to pay benefits to the NECA-IBEW Welfare Trust Fund, the NECA-IBEW Pension Trust Fund, and/or the IBEW-NECA Conduit 401(k) Plan electronically via Electronic Funds Transfer (EFT) through the EPRLive platform.

Form for employers to complete to detail their business information for the Fund Office.

The NECA-IBEW Pension Trust Fund collection and payroll audit policy.

This notice provides a summary of plan information to employers and employee organizations regarding the NECA-IBEW Pension Trust Fund.

Summarizes the changes to the Fund's policies and procedures for remittance of employer contributions and payroll compliance audits/examinations for the Pension Trust Fund.

Chart of Pension Trust Fund participation options and supporting information.

The agreement and declaration of trust that the Union has with Employers, requiring payments by the Employers into a Trust Fund for the purpose of maintaining pension benefits.

Form for employers to waive coverage in the NECA-IBEW Pension Trust Fund for non-bargaining unit employees.

This document defines the terms and conditions that apply to all participation agreements between any employer and the NECA-IBEW Welfare Trust Fund covering employer participation.

Form for employers to complete to detail their business information for the Fund Office.

Describes the Collection and Payroll Audit Policy, which is a collection policy to assure fulfillment of the Fund's fudiciary duty to collect delinquent employer contributions.

Participation agreement, required by the Labor-Management Relations Act, which allows the Welfare Trust Fund to receive contributions from Employers on behalf on non-bargaining employees and to allow these employees to participate in the Base Plan and HRA.

Participation agreement, required by the Labor-Management Relations Act, which allows the Welfare Trust Fund to receive contributions from Employers on behalf on non-bargaining employees and to allow these employees to participate in the Base Plan.

Participation agreement, required by the Labor-Management Relations Act, which allows the Welfare Trust Fund to receive contributions from Employers on behalf on non-bargaining employees and to allow these employees to participate in the Alt Plan and HRA.

Participation agreement, required by the Labor-Management Relations Act, which allows the Welfare Trust Fund to receive contributions from Employers on behalf on non-bargaining employees and to allow these employees to participate in the Alt Plan.

Participation agreement, required by the Labor-Management Relations Act, which allows the Welfare Trust Fund to receive contributions from Employers on behalf on non-construction bargaining employees and to allow these employees to participate in the Base Plan.

Participation agreement, required by the Labor-Management Relations Act, which allows the Welfare Trust Fund to receive contributions from Employers on behalf on non-construction bargaining employees and to allow these employees to participate in the Alt Plan.

Summarizes the changes to the Fund's policies and procedures for remittance of employer contributions and payroll compliance audits/examinations for the Welfare Trust Fund.

Chart of Welfare Trust Fund participation options and supporting information.

Form for employers to waive coverage in the NECA-IBEW Welfare Trust Fund for non-bargaining unit employees.

Participation agreement, required by the Labor-Management Relations Act, which allows the Welfare Trust Fund to receive contributions from Employers on behalf on former bargaining unit alumni employees and working owner employees, and to allow these employees to participate in the Base Plan.

Participation agreement, required by the Labor-Management Relations Act, which allows the Welfare Trust Fund to receive contributions from Employers on behalf on former bargaining unit alumni employees and working owner employees, and to allow these employees to participate in the Alt Plan.

Frequently Asked Questions about the Employee Assistance Program (EAP); a work-life/well-being resource that provides confidential consultations, information and resources, connections to community agencies and supports, and referrals to counseling.

Overview of the Employee Assistance Program (EAP) that provides immediate and confidential help for any work, health or life concern.

Examples of what issues the Employee Assistance Program (EAP) can assist with.

How to use the Employee Assistance Program (EAP), including contact information.

The form to use to request withdrawal from the Conduit 401(k) Plan for Participants age 59 1/2.

This form is to select a beneficiary for the 401(k) plan.

The form to use to specify a distribution election for distribution from the Conduit 401(k) Plan to another plan or for payment to the Participant.

The enrollment form to use to enroll in the Conduit 401(k) plan and to select investments.

The form to use to request a hardship withdrawal from the Conduit 401(k) Plan.

This form is used to select payment options for minimum distributions from the 401(k) Plan that are required under federal law for participants who are 5% owners and terminated participants who have attained the age of 73.

The form to use to complete to roll over amounts from an eligible retirement plan to the Conduit 401(k) Plan.

The form to use to indicate if you are subject to backup withholding because you failed to report all interest and dividends on your tax return.

The Agreement and Declaration of Trust between the Union and the Association to create the Conduit 401(k) Fund and Plan.

This amendment to the Conduit 401(k) Plan Document deals with the time of commencement of benefit payments and minimum distribution requirements.

This amendment to the Conduit 401(k) Plan Document deals with eliminating loan requirements-hardship.

This amendment to the 401(k) Trust Agreement deals with investments of trust assets.

This amendment to the Conduit 401(k) Trust Agreement deals with liquidated damages.

This notice describes the employer's option to pay benefits to the IBEW-NECA Conduit 401(k) Plan electronically via Electronic Funds Transfer (EFT) through the EPRLive platform.

This booklet is called a Summary Plan Description (SPD) and is intended to provide a brief description of the Conduit 401(k) Plan.

This form outlines the basic requirements and the required documentation for eligible reasons for a hardship withdrawal from your 401(k).

This notice describes the rollover rules that apply to payments from the Plan.

This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.

This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.

This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.

This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.

This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.

This notice contains important information about your right to continue your health care coverage in the NECA-IBEW Welfare Trust Fund (the Fund), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace.

To preserve your right to elect COBRA, you or your qualified beneficiary must complete this form to notify the Fund Office within 60 days of when your coverage would end due to legal separation, divorce, or your dependent child ceasing to have “dependent” status.