FORMS AND RESOURCES
FORMS
For your convenience, electronic versions of some frequently used forms are provided below. For other forms (Enrollment/Changes, Beneficiary, Wage Indemnity, SUB Plan, Income Continuance, Life/AD&D) please contact the Welfare Plan office.
- Optical Claim Form
- PBC Claim Form – Active Employees
- PBC Claim Form – Retired
- Children’s Orthodontics Reimbursement Slips 2021
- Bereavement Wage Loss Reimbursement Form
- Jury Duty Reimbursement Form
- Pro-Rating on Dental/Hearing Aids – How it Works
ANNUAL REPORTS
- 2023 Annual Summary Newsletter
- 2023 Annual Report (Full Version)
- 2022 Annual Summary Newsletter
- 2022 Annual Report (Full Version)
- 2021 Annual Report (Full Version)
PACIFIC BLUE CROSS BOOKLETS, ETC.
Booklets Prior to January 1, 2024
- Local 213 Active Employees Pacific Blue Cross booklet < 65
- Local 213 Active Employees Pacific Blue Cross booklet 65+
- Local 213 Retired Employees Pacific Blue Cross booklet
Booklets Effective January 1, 2024
- Local 213 Active Employees Pacific Blue Cross booklet < 65
- Local 213 Active Employees Pacific Blue Cross booklet 65+
- Local 213 Retired Employees Pacific Blue Cross booklet
MEMBER & FAMILY ASSISTANCE PROGRAM MATERIALS
- Members and Family Assistance Program Overview
- Homeweb – Online Resources Fact Sheet
- EFAP Orientation Registration
WAGE INDEMNITY
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RECORDED INFORMATION SESSIONS
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