Forms

You can download and print the TBT forms posted below. Contact the TBT Plan Administration Office if you are not sure which forms apply to you.

Address Changes

Keep your address current, so you’ll receive up-to-date information about your benefits. Remember, TBT keeps one address for each participant. If your spouse or covered dependents don’t live with you, make sure they know that all TBT mail is sent to your address.

Change of Address Card: Participant (PDF) | Retiree (PDF)

Enrollment Materials

The TBT Plan Administration Office automatically sends a new participant enrollment packet to you (at the address provided by your Employer when Plan contributions are sent to TBT on your behalf). If you need to enroll and have not yet received your enrollment materials, contact the TBT Plan Administration Office.

Enrollment for you and your eligible dependents is not automatic. If you don’t send in the required enrollment forms within 30 days after you and your covered dependents become eligible, the coverage may be delayed—or even denied if you choose an HMO.

For your convenience, TBT enrollment forms are posted below. Download the enrollment forms that apply to you, fill them out, and fax or mail to the TBT Plan Administration Office.

Enrollment Forms for Active Participants

Follow these steps to complete the enrollment process by your enrollment deadline (mentioned above): 

  1. Complete the TBT Enrollment Form (PDF)
  2. Complete the TBT Medical Option Form (PDF)
  3. Complete the TBT Dental Option Form (PDF)
  4. Complete an HMO Application Form (if choosing a non-Medicare HMO option under your TBT Plan):
    Kaiser Enrollment Application: English (PDF) | Spanish (PDF)
     Note: The current Kaiser enrollment and change form will be accepted until 3/31/2018
    United HealthCare Application (PDF)
  5. Send your TBT Enrollment Form, Medical Option Form, Dental Option Form, HMO application, birth or adoption certificates for all members of your family, and a marriage certificate if you are married, to the TBT Plan Administration Office.

Do not assume that you are enrolled in your new coverage until you receive confirmation.

MAIL to TBT Plan Administration Office, 39420 Liberty Street, Suite 260, Fremont, CA 94538-2200
Or FAX to (510) 795-9237
Or EMAIL to enroll@lipmantpa.com

REMINDERS

Don’t forget to fill in all sections and sign and date the forms before submitting them with the required legal documents. When sending by fax or email, call the TBT Plan Administration Office at (800) 533-0119 after a few days to confirm that your materials are received.

Enrollment Forms for Retirees

Your application for TBT retiree benefits cannot be processed until the TBT Plan Administration Office receives all required forms (as explained below).

Note: A self-pay contribution is also required under the Retirement Security Plan (RSP Silver), Basic Retiree Plan (BRP) or Comprehensive Retiree Plan (CRP). To avoid enrollment delays, send the first payment along with the Automated Direct Payment Form posted in the next section.

Follow these steps to complete the retiree enrollment process:

  1. Complete the Application for Retiree Benefits (All Retiree Plans) (PDF)
  2. Complete the Retiree Enrollment Form (All Retiree Plans) (PDF)
  3. Complete the Retiree Medical Option Form (CRP and RSP only) (PDF)
  4. Complete the RSP Dental Option Form (RSP only) (PDF)
  5. Complete an HMO Application Form (if choosing HMO option under CRP or RSP):
    Kaiser Enrollment/Change Form (Senior Advantage HMO) (PDF)
    United Healthcare Enrollment Form (United Healthcare HMO) (PDF)
  6. Send your required forms, and a marriage certificate if you are married, to the TBT Plan Administration Office for receipt by the enrollment deadline:

MAIL to TBT Plan Administration Office, 39420 Liberty Street, Suite 260, Fremont, CA 94538-2200
Or FAX to (510) 795-9237
Or EMAIL to Retiree_COBRA@lipmantpa.com

Reminders

Don’t forget to fill in all sections and sign and date the forms before submitting them with the required legal documents. When sending by fax or email, call the TBT Plan Administration Office at (800) 533-0119 after a few days to confirm that your materials are received.

TBT Retiree Direct Payment Automated Deposit Forms

Monthly self-pay contributions are required under the Retirement Security Plan (RSP Silver), Basic Retiree Plan (BRP) or Comprehensive Retiree Plan (CRP). Retiree participants who enroll in these Plans are encouraged to authorize a bank or financial institution to make automated self-payment deposits on their behalf by completing the appropriate form below. Be sure to attach a copy of a voided check when you send your Plan’s bank authorization form back to the TBT Plan Administration Office:

BRP Authorization Direct Payment Form (PDF)
CRP Authorization Direct Payment Form (PDF)
RSP Silver Authorization Direct Payment Form (PDF)

Open Enrollment Policy

TBT’s Open Enrollment policy allows covered participants and retirees to change medical and/or dental options once every 12 months between January 1 and December 31. Unless you make changes, your current medical and dental options stay in effect.

Indemnity Medical Claim Forms

You rarely need to file a claim for medical benefits when you use Anthem Blue Cross PPO providers. The provider or hospital usually sends the claim to TBT. If not, it is your responsibility to file the claim using the forms below:

Indemnity Medical Claim Form: Participant (PDF) | Retiree (PDF)

Important Reminder: Under the Indemnity Medical option, failure to use the Plan’s PPO providers will result in a reduction of benefits. Click here for details on how to find participating providers in the Anthem Blue Cross PPO network (PDF).

Indemnity Dental Claim Forms

You rarely need to file a claim for dental benefits when you use Delta Dental providers. If forms are needed, ask your dentist to use the forms posted below:

Indemnity Dental Claim Form:  Participant (PDF) | Retiree (PDF) | Supplemental Dental (PDF)

TBT Coordination of Benefits (COB) Questionnaire

If you or any of your eligible dependents have TBT medical benefits and are also covered by another group plan, the benefit payable by this Plan may be reduced. Benefit payments are coordinated between the plans so that you do not receive payment for more than 100% of the Usual, Customary and Reasonable (UCR) medical expenses for the covered treatment. The benefits payable under the Plan will not be greater than the actual amount that would have been paid if there were no other group plan involved.

Coordinated benefits cannot be determined and claims will NOT be paid until you complete the Coordination of Benefits (COB) Questionnaire (posted below) and return it to the TBT Plan Administration Office. If you have questions, please call 800-533-0119 and ask for the Claims Customer Service Unit.

A new Coordination of Benefits Questionnaire must be re-submitted every 12 months to TBT at the address shown on the form.

Coordination of Benefits Form: TBT COB Questionnaire (PDF)

Extension of Benefits Disability Claim Form

If you are eligible but rendered unable to work because you become totally disabled as a result of an illness or injury, coverage for you and your covered dependents will continue for up to three months. Coverage is not automatic. You must apply for the extension of benefits by sending all the required forms and documentation to the TBT Plan Administration Office as requested. Call (800) 533-0119 and ask for the Disability Call Center as soon as your doctor determines that you will be out on disability.

Proof of Disability Form (PDF)

HIPAA Privacy Disclosure Form

Click below to print the form needed to provide the TBT Plan Administration Office with your written permission to use or disclose specific health information:

TBT Authorization to Obtain and Disclose Personal Health Information (PDF)