Health Forms

Complete & 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 the Plan Office. These printable forms are in PDF format. To read and print them, you need the free Adobe Reader. Click here to install Adobe Reader.

General

  • Eligibility and Premium Rules Sheet — This document provides a summary of the rules and requirements to qualify for coverage, premium amounts, premium due dates and time limits associated with open enrollment.
  • Privacy Notice — The privacy of your personal health information has always been of paramount importance to the Plan. Recent federal regulations require that the Plan provide all participants with a written notice of its privacy practices. This notice can be viewed here.
  • Performer Information Form — The Performer Information Form is the primary source for demographic information for each participant.
  • New Dependent Form — This form is used to add new dependents. You as the Participant must be covered in order for coverage to be extended to your dependents.
  • Designation of Beneficiary for Life Insurance — This form designates your beneficiaries. Please refer to the instructions while filling this form out.
  • Annual Summary of Earnings — This is a record of all session and residual earnings reported on your behalf to the Pension and Health Plans during the calendar year. It also reflects your total Pension Credits and accrued benefits under the Pension Plan.
  • Authorization For Release of Health Information — This form is used when a participant wishes to authorize that their health information be disclosed to a particular person or organization.
  • Notice of Creditable Coverage — This Notice contains important information about the prescription drug coverage with the SAG-Producers Health Plan and the Medicare Prescription Drug Plan (PDP) coverage.
  • 2016 Plan I SBC (Effective 01/01/16) — A summary of Plan I benefits, including cost sharing provisions and major exclusions for 01/01/2016 through 12/31/2016.
  • 2016 Plan II SBC (Effective 01/01/16) — A summary of Plan II benefits, including cost sharing provisions and major exclusions for 01/01/2016 through 12/31/2016.
  • Glossary — A standard glossary of common health coverage and medical terms. The glossary is intended to be educational and the terms may not have exactly the same meaning when used by the Plan.

Health Plan Premium

  • Earned Premium Payment Chart — This chart gives a handy comparison of the four methods available to pay premiums.
  • Auto Debit Application — Your premium is automatically deducted on a recurring basis from a U.S. checking or savings account. If you are covered under the Self-Pay, Senior Performer or Extended Spousal plan, your payments will be deducted monthly on the 25th of the month prior to the due date. If you have Earned plan coverage, your premiums will be deducted quarterly on the 25th of the month prior to each quarter. Start using Auto Debit by registering online or providing the Health Plan with a signed hard copy.

Claim Forms

Disability

2016 Self-Pay Information and Forms