Level C Forms
Level C Enrollment Form
If you have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator’s office at Open Enrollment (November 20th through December 20th). NOTE: Submitting an enrollment application is not proof of enrollment.
Kaiser Permanente Claim Form for Emergency Medical Services
To request reimbursement for emergency services received at a non-Kaiser Permanente facility.
EyeMed Claim Form
Coming soon
Life Application / Beneficiary Form
All eligible participants complete the beneficiary/enrollment form to be enrolled in Life Insurance. Please print and complete this form to designate a beneficiary, return completed form to the Trust Administrative office.
Waiver of Coverage
If you have been notified that you are eligible for benefits, but have decided not to enroll, print and complete. Upon certain conditions you may reserve your and your dependent’s right to enroll at a later date.
Submitting Forms
Claim forms should be sent to the appropriate benefit provider at the address listed on the form.
All other forms should be sent to:
Musicians Health and Welfare
c/o PacFed Benefit Administrators
200 S. Los Robles Ave., Suite 320
Pasadena, CA 91101
Glossary of Health Coverage and Medical Terms
This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.)