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| Document Name | Description |
|---|---|
| March 2025 Summary Plan Description | Describes the benefits offered through the DGA-Producer Pension Plans. |
| 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. |
| Benefit Application Request Form | This is the form requesting a retirement application package from the DGA-Producer Pension Plans. This is not the retirement application. |
| California State Tax Withholding Form | This form allows you to elect to have or not have California Personal Income Tax withheld from periodic or nonperiodic pension or annuity payments. You may also complete this form to claim California Personal Income Tax withholding allowances or to change or revoke a previously filed California State Tax Withholding Form. |
| 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-4P | If you currently receive a monthly benefit payment from the DGA-Producer Basic Pension Plan, complete this form to update your withholding elections for annuity payments. |
| IRS Form W-4R | If you currently receive a benefit payment from the DGA-Producer Supplemental Pension Plan, complete this form to update your withholding elections for annuity payments. |
| 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. |
| Supplemental Plan Additional Distribution Request Form | This form is only for participants who have previously received or are currently receiving distributions from the Supplemental Plan and who would like to request another Supplemental Plan Distribution Application in order to request an additional distribution from the Supplemental Plan. |
| 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. |
| Third Party Authorization Form | This form authorizes the Pension Plans to release confidential Pension Plans information to a third party. |
| Document Name | Description |
|---|---|
| March 2025 Health Plan Summary Plan Description | Describes the benefits offered through the DGA-Producer Health Plan |
| Accident Information Form | This form is used to provide information about an accident or injury related to a claim. |
| Adult Dependent Authorization Form | This form is for use by an adult Health Plan participant who is eligible as a dependent and who wishes to have all of his/her Health Plan mail (including Explanations of Benefits and other claims information) sent to and checks made out to his/her parent or spouse who is the primary Plan participant. |
| Application for COBRA Premium Assistance for Entertainment Industry Employees | The New York State COBRA Premium Assistance Program helps NY-based entertainment industry employees maintain health coverage. Eligible applicants can receive premium assistance equal to 75% of their COBRA premiums for up to 12 months within a five-year period. |
| 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 U.S. | This form needs to be completed when submitting medical claims for services received in the United States. |
| Claim Form – Medical – Services Received Outside the U.S. | This form needs to be completed when submitting medical claims for services received outside the U.S. 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-CVS Caremark network 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 CVS Caremark, for partial reimbursement. If you visit a CVS Caremark network 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. |
| 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. |
| 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. | |
| Health Services and Assistance for Non-Covered Participants | This document lists sources of medical services and assistance for individuals without health coverage. Listed organizations are not affiliated with the DGA-Producer Pension and Health Plans; therefore, the Plans cannot offer assurance you will meet established qualifications. |
| Paid Parental Leave Benefit Guide and Application | This document describes the Paid Parental Leave Benefit and includes the Paid Parental Leave Benefit Application. |
| 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. |
|
Summaries of Benefits and Coverage
|
Eight-page plan summaries including information about covered benefits, cost sharing and exclusions, accompanied by a standard glossary of common insurance and medical terms. |
| Document Name | Description |
|---|---|
| Adult Dependent Authorization Form | This form is for use by an adult Health Plan participant who is eligible as a dependent and who wishes to have all of his/her Health Plan mail (including Explanations of Benefits and other claims information) sent to and checks made out to his/her parent or spouse who is the primary Plan participant. |
| Change of Address Form | Please file the Change of Address form with the Plans whenever you move. |
| Document Name | Description |
|---|---|
| March 2025 Summary Plan Description | Describes the benefits offered through the DGA-Producer Pension Plans. |
| 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. |
| Benefit Application Request Form | This is the form requesting a retirement application package from the DGA-Producer Pension Plans. This is not the retirement application. |
| California State Tax Withholding Form | This form allows you to elect to have or not have California Personal Income Tax withheld from periodic or nonperiodic pension or annuity payments. You may also complete this form to claim California Personal Income Tax withholding allowances or to change or revoke a previously filed California State Tax Withholding Form. |
| 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-4P | If you currently receive a monthly benefit payment from the DGA-Producer Basic Pension Plan, complete this form to update your withholding elections for annuity payments. |
| IRS Form W-4R | If you currently receive a benefit payment from the DGA-Producer Supplemental Pension Plan, complete this form to update your withholding elections for annuity payments. |
| 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. |
| Supplemental Plan Additional Distribution Request Form | This form is only for participants who have previously received or are currently receiving distributions from the Supplemental Plan and who would like to request another Supplemental Plan Distribution Application in order to request an additional distribution from the Supplemental Plan. |
| 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. |
| Third Party Authorization Form | This form authorizes the Pension Plans to release confidential Pension Plans information to a third party. |
| Document Name | Description |
|---|---|
| March 2025 Health Plan Summary Plan Description | Describes the benefits offered through the DGA-Producer Health Plan |
| Accident Information Form | This form is used to provide information about an accident or injury related to a claim. |
| Adult Dependent Authorization Form | This form is for use by an adult Health Plan participant who is eligible as a dependent and who wishes to have all of his/her Health Plan mail (including Explanations of Benefits and other claims information) sent to and checks made out to his/her parent or spouse who is the primary Plan participant. |
| Application for COBRA Premium Assistance for Entertainment Industry Employees | The New York State COBRA Premium Assistance Program helps NY-based entertainment industry employees maintain health coverage. Eligible applicants can receive premium assistance equal to 75% of their COBRA premiums for up to 12 months within a five-year period. |
| 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 U.S. | This form needs to be completed when submitting medical claims for services received in the United States. |
| Claim Form – Medical – Services Received Outside the U.S. | This form needs to be completed when submitting medical claims for services received outside the U.S. 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-CVS Caremark network 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 CVS Caremark, for partial reimbursement. If you visit a CVS Caremark network 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. |
| 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. |
| 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. | |
| Health Services and Assistance for Non-Covered Participants | This document lists sources of medical services and assistance for individuals without health coverage. Listed organizations are not affiliated with the DGA-Producer Pension and Health Plans; therefore, the Plans cannot offer assurance you will meet established qualifications. |
| Paid Parental Leave Benefit Guide and Application | This document describes the Paid Parental Leave Benefit and includes the Paid Parental Leave Benefit Application. |
| 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. |
|
Summaries of Benefits and Coverage
|
Eight-page plan summaries including information about covered benefits, cost sharing and exclusions, accompanied by a standard glossary of common insurance and medical terms. |
| Document Name | Description |
|---|---|
| Adult Dependent Authorization Form | This form is for use by an adult Health Plan participant who is eligible as a dependent and who wishes to have all of his/her Health Plan mail (including Explanations of Benefits and other claims information) sent to and checks made out to his/her parent or spouse who is the primary Plan participant. |
| Change of Address Form | Please file the Change of Address form with the Plans whenever you move. |
