Forms

Complete and Print Forms - You can complete most of the forms listed below right on your computer before you print. Simply click on a field in the form and type in the appropriate information. Then print the completed form, sign and mail it to Carpenters Trusts. These printable forms are in PDF format. To read and print them, you need the free Adobe Reader (which is probably already installed in your system). Click here if you do not have Adobe Reader installed on your system.

• Enrollment

  Enrollment Application - Health and Security — To properly enroll in the Carpenters Health and Security Plan, you must complete this form in its entirety and return it to Carpenters Trusts. We cannot process your health care claims and vacation contributions without your completed form on file at the Carpenters Trusts. Please mail this form to: Northwest Carpenters Trusts. The mailing address, website and telephone number are on the reverse side of this form.

  Solicitud de inscripción — Salud y seguridad: para inscribirse correctamente en el plan de salud y seguridad de Carpenters, debe completar este formulario en su totalidad y enviarlo a Carpenters Trusts. No podemos procesar sus reclamaciones de atención médica y contribuciones de vacaciones sin que haya completado su formulario en Carpenters Trusts. Envíe este formulario por correo a: Northwest Carpenters Trusts. La dirección de correo, el sitio web y el número de teléfono se encuentran en el reverso de este formulario.

  Dependent Enrollment Application — To enroll a new dependent in the Carpenters Health and Security Plan, you must complete this form in its entirety and return it to Northwest Carpenters Trusts. The mailing address, website and telephone number are on the reverse side of this form.

  Solicitud de inscripción de personas dependientes — Para inscribir a un nuevo dependiente en el Plan de salud y seguridad de Carpenters, complete este formulario en su totalidad y devuélvalo a Northwest Carpenters Trusts. La dirección postal, el sitio web y el número de teléfono se encuentran en el reverso de este formulario.

  Domestic Partner Enrollment Affidavit — Review this document for instructions to enroll a domestic partner. Complete and sign the last page of this document and return the signed copy to Northwest Carpenters Trusts.

  2024 Open Enrollment Form — Once each year, Oregon participants are allowed to change medical coverage from the Northwest Carpenters Health and Security Plan to the Kaiser Permanente Plan, or vice versa. To change your medical plan, complete this form and return to Northwest Carpenters Trusts no later than December 16, 2023 for coverage effective January 1, 2024.

  Authorization To Release/Use Protected Health Information (PHI) — Complete this form to authorize the access, sharing and use of your PHI by individuals and/or organizations.

  Change of Address — Please fill out this form and submit it to Carpenters Trusts if your address has changed. (Tip: For a paperless method, log in to the Member Portal and click My Profile.)

  Authorization To Transfer Contributions — If you are working outside the jurisdiction of your home trust and your benefit contributions are being sent to a cooperating trust, use this form to have your contributions sent back to your home trust. Deliver your completed form to the cooperating/away trust.

  Authorization To Terminate Transfer of Contributions — If you are working in the jurisdiction of a cooperating trust and having benefit contributions sent to your home trust, use this form to discontinue the transfer of contributions. Deliver your completed form to the cooperating/away trust.

  Change of Beneficiary — Use this form to designate a different person to receive your Life Insurance benefit and/or Carpenters Retirement Plan benefit, if applicable.

• Self-Contribution Coverage

  2024 Self-Contribution Notice — This letter provides eligibility requirements, cost, and duration of coverage information for Self-Contribution Coverage.

  2024 Self-Contribution Application for Washington — Fill out this form to apply for Self-Contribution Coverage.

  2024 Self-Contribution Application for Washington - USERRA — Fill out this form to apply for Self-Contribution Coverage.

  2024 Self-Contribution Application for Oregon — Fill out this form to apply for Self-Contribution Coverage.

  2024 Self-Contribution Application for Oregon - Kaiser — Fill out this form to apply for Self-Contribution Coverage.

  2024 Self-Contribution Extension Application — Use this form to apply for an extension of Self-Contribution Coverage.

  2024 Self-Contribution Certificate of Disability — Use this form to fill out the Carpenter's Statement of Disability. Your attending physician must complete the Attending Physician's Statement of Disability.

• COBRA

  2024 COBRA Coverage Election Notice — Contains information of your COBRA Continuation Coverage rights.

  2024 COBRA Application for 18-Month Qualifying Event (Washington) — Use this form if you are a participant losing dollar bank eligibility.

  2024 COBRA Application for 18-Month Qualifying Event - (Oregon) — Use this form if you are a participant losing dollar bank eligibility.

  2024 COBRA Application for 18-Month Qualifying Event - Kaiser (Oregon) — Use this form if you are a participant losing dollar bank eligibility.

  2024 COBRA Application for 36-Month Qualifying Event - Retiree (Washington) — This form is for a dependent with a loss of eligibility.

  2024 COBRA Application for 36-Month Qualifying Event (Washington) — This form is for a dependent spouse following a divorce, legal separation, death of a spouse, or a dependent child's loss of eligibility.

  2024 COBRA Application for 36-Month Qualifying Event (Oregon) — This form is for a dependent following a divorce, legal separation, or death of a spouse, or a dependent child's loss of eligibility.

  2024 COBRA Application for 36-Month Qualifying Event - Kaiser (Oregon) — This form is for a dependent following a divorce, legal separation, or death of a spouse, or a dependent child's loss of eligibility.

  2024 COBRA Application for 11-Month Qualifying Event (Washington) — This form is for a participant or dependent with a disability.

  2024 COBRA Application for 11-Month Qualifying Event (Oregon) — This form is for a participant or dependent with a disability.

  2023 Forms — If you need a 2023 application, click here.

• Retiree Coverage

  2024 General Notice of Retiree Coverage Plan Rights — One of the more important decisions you will face when you retire is how best to maintain health care coverage for you and your family. The Northwest Carpenters Health and Security Plan has four options under which eligible retirees may obtain health care coverage after retirement. The information in this notice should help you decide which option is best for you and your family.

  2024 Retiree Coverage Plan Application (Oregon) — If you qualify, there is a specific window of time in which you are permitted to apply. Return your completed application as soon as possible.

  2024 Retiree Coverage Plan Application - No Dental or Vision (Washington) — If you qualify and would like to participate in Retiree Coverage, you must complete this application and return it to Northwest Carpenters Trusts. Your career hours are available on your quarterly benefit statement or contact Participant Services at Northwest Carpenters Trusts.

  2024 Retiree Health Reimbursement Arrangement (HRA) Plan Application — If you are retired and eligible for Retiree Coverage or COBRA, you may pay a portion of your monthly premium from your Retiree Health Reimbursement Arrangement (HRA) Plan. Please complete this application and return it to Carpenters Trusts.

• Medical

  Regence Claim Form — If a provider will not bill the plan directly by sending charges to Regence, a patient can submit a claim for reimbursement with this form. Read the instructions on last page before completing, then mail to: Regence BlueShield, PO Box 1106, Lewiston, ID 83501. You may also fax the form to Regence at: (888) 606-6582. To submit your claim online, create an account and sign in at www.regence.com.

• Prescription Drug

  Express Scripts Fax Order Form — Print this form or Log In to your Express Scripts account to print a personalized fax form to give to your doctor.

  Express Scripts Mail Order Form — This form is used to order medications from Express Scripts.

  Prescription Drug Reimbursement Form — This form is used to apply for reimbursement of drugs for a participant eligible for drug benefits.

• Vision

  VSP Member Reimbursement Form (Vision) — This form should be used only for services received from a non-network provider.

• Time Loss

  Time Loss Application - Employed Carpenters — Use this form to apply for Time Loss Benefits. The first section must be filled out by the Carpenter, and the second by the Carpenter's attending physician. Mail the completed form to Carpenters Trusts.

  Time Loss Benefits For Mental Health Disability - Employed Carpenters — Use this form to apply for Time Loss Benefits for Mental Health Disability. The first section must be filled out by the Carpenter, and the second by the Carpenter's attending physician. Mail the completed form to Carpenters Trusts.

  Time Loss Benefits Update - Employed Carpenters — Use this form to apply for Time Loss Benefits Update. The first section must be filled out by the Carpenter, and the second by the Carpenter's attending physician. Mail the completed form to Carpenters Trusts.

• Life Insurance

  Life Insurance Beneficiary — Use this form to name a beneficiary for life insurance benefits under the Carpenters Health and Security Plan.

• Claims

  Injury Questionnaire — This questionnaire is used by the Trust to document accidental injuries.

  Life Insurance Form — Please contact Participant Services at (800) 552-0635 for a life insurance form.

  Motor Vehicle Accident Report — If you or a covered dependent were involved in a motor vehicle accident, complete this form and return it to Northwest Carpenters Trusts. A signed Reimbursement Agreement is also required.

  Personal Injury Questionnaire — This questionnaire is required to gather basic facts about a personal injury. Return the signed form to Northwest Carpenters Trusts. A signed Reimbursement Agreement is also required.

  Reimbursement Agreement - Third-Party or Insurer — Complete this form when someone else caused an accident or illness, and a third party or insurance company is financially responsible.