Documents and Forms

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Spotlight on Benefits Newsletters
Volume 24, Number 2 Summer 2016
Volume 24, Number 1 Spring 2016
Volume 23, Number 3 Winter 2015
Volume 23, Number 2 Fall 2015
Volume 23, Number 1 Spring 2015
Volume 22, Number 3 Winter 2014
Volume 22, Number 2 Summer 2014
Volume 22, Number 1 Spring 2014
Benefits Bulletin December 2013
Volume 21, Number 3 Fall 2013
Volume 21, Number 2 Summer 2013
Volume 21, Number 1 Spring 2013

 

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Address Change Forms
Change of Address Form Please file the Change of Address form with the Plans whenever you move.
E-Delivery Opt-in Form This form is required in order to receive your pension and health related documents electronically instead of by mail as documents become available.

 

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Health Plan Documents and Forms
March 2015 Health Plan Booklet Describes the benefits offered through the DGA-Producer Health Plan
March 2015 Health Plan Booklet Updates A list of updates to the 2015 Health Plan booklet since March 2015.
Change of Address Form Please file the Change of Address form with the Plans whenever you move.
Claim Form - Dental When you visit a non-Delta Dental dentist, this form must be filled out and be accompanied by an itemized bill. If you visit a Delta Dental dentist, the dentist will take care of the paperwork.
Claim Form - Medical – Services Received in the US (in California) This form needs to be completed when submitting medical claims for services received in California.
Claim Form - Medical – Services Received in the US (outside California) This form is to be completed when submitting medical claims for services received outside of California.
Claim Form – Medical – Services Received Outside the US This form needs to be completed when submitting medical claims for services received outside the US.  Claim forms along with any itemized bills do not have to be translated into English or dollars.
Claim Form - Prescription When you obtain prescription drugs from a non-Express Scripts pharmacy, you will have to pay the full amount of the purchase to the pharmacy and then fill out this claim form and submit it to Express Scripts, formerly known as Medco, for partial reimbursement. If you visit an Express Scripts pharmacy, there is no paperwork.
Claim Form - Vision When you visit a non-VSP vision provider, this form must be filled out and accompanied by an itemized bill. If you visit a VSP provider, the provider will take care of all of the necessary paperwork.
Coordination of Benefits Form This form is submitted prior to the Health Plan processing claims for you and your dependents to provide the Health Plan with information regarding your other health insurance, if any. This information is required so that we can coordinate benefit payment with your other insurance.
Dental Election Form California participants can complete and return this form during their open enrollment period to switch from the Delta Dental PPO Plan to the DeltaCare Dental HMO Plan, or vice-versa.
Dependent Enrollment Form This form must be submitted to the Health Plan when enrolling new dependents under your health coverage.
HIPAA Authorization Form This form authorizes the Health Plan to release Protected Health Information to designated individuals or institutions.
HIPAA Notice of Privacy Practices This details the Health Plan's privacy practices regarding protected health information.
Life Events Fact Sheets Getting married. Having a baby. Preparing for retirement. These are the moments in life when your benefits matter most. With that in mind, we have developed the Life Events fact sheets to help ensure that you get all of the information that you need regarding how these events will affect your benefits as well as what action, if any, you need to take.
Pension Deduction Authorization Form This form authorizes the Health Plan to collect your health care premium directly from your Basic Plan monthly pension benefit each month. This is only for participants on regular or retiree self-pay coverage. This option is not available for dependent premium payment.
Summary of Benefits and Coverage An eight page summary including information about covered benefits, cost sharing and exclusions, accompanied by a standard glossary of common insurance and medical terms.

 

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Pension Plan Documents and Forms
March 2015 Summary Plan Description Describes the benefits offered through the DGA-Producer Pension Plans.
March 2015 Summary Plan Description Updates A list of updates to the 2015 Summary Plan Description since March 2015.
Basic Plan Withholding Form If you are receiving a monthly pension benefit from the DGA-Producer Basic Pension Plan, this form allows you to elect the amount of Federal and State taxes that will be withheld from your monthly pension benefit.
Beneficiary Designation Form This form allows you to designate a beneficiary or beneficiaries to receive your Basic and Supplemental Plan benefits, in the event of your death.
Change of Address Form Please file the Change of Address form with the Plans whenever you move.
Direct Deposit Form If you would like to have your monthly pension benefit deposited directly into your bank account, please fill out this form and mail it to the Plans office.
Employment Recap Form If you are retired from the Basic Pension Plan and have returned to DGA covered employment, complete this form to provide a recap of your recent employment.
IRS Form W-7 This is the Internal Revenue Service Application for IRS Individual Taxpayer Identification Number form.
IRS Form W-8BEN This is the Internal Revenue Service Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding form.
Retirement Application Request Form This is the form requesting a retirement application package from the DGA-Producer Pension Plans. This is not the retirement application.
Supplemental Plan Incoming Rollover Form This form must be submitted to the Pension Plan office if you are planning on rolling funds from a qualified plan into your Supplemental Plan account.
Supplemental Plan - Post-Retirement Distribution Application Request Form If you have taken a distribution from the Supplemental Plan and currently have an account balance, complete this form if you would like to take a partial distribution, purchase an annuity(ies), or take a full lump sum.
Third Party Authorization Form This form authorizes the Pension Plans to release confidential Pension Plans information to a third party.  

 

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