You can download and print the TBT forms posted below. Contact the TBT Plan Administration Office if you are not sure which forms apply to you.
Address Changes
Keep your address current, so you’ll receive up-to-date information about your benefits. Remember, TBT keeps one address for each participant. If your spouse or covered dependents don’t live with you, make sure they know that all TBT mail is sent to your address.
Change of Address Card: Participant (PDF) | Retiree (PDF)
TBT Retiree Direct Payment Automated Deposit Forms
Monthly self-pay contributions are required under the Retirement Security Plan (RSP Silver), Basic Retiree Plan (BRP) or Comprehensive Retiree Plan (CRP). Retiree participants who enroll in these Plans are encouraged to authorize a bank or financial institution to make automated self-payment deposits on their behalf by completing the appropriate form below. Be sure to attach a copy of a voided check when you send your Plan’s bank authorization form back to the TBT Plan Administration Office:
BRP Authorization Direct Payment Form (PDF)
CRP Authorization Direct Payment Form (PDF)
RSP Silver Authorization Direct Payment Form (PDF)
Open Enrollment Policy
TBT’s Open Enrollment policy allows covered participants and retirees to change medical and/or dental options once every 12 months between January 1 and December 31. Unless you make changes, your current medical and dental options stay in effect.
Indemnity Medical Claim Forms
You rarely need to file a claim for medical benefits when you use Anthem Blue Cross PPO providers. The provider or hospital usually sends the claim to TBT. If not, it is your responsibility to file the claim using the forms below:
Indemnity Medical Claim Form: Participant (PDF) | Retiree (PDF)
Important Reminder: Under the Indemnity Medical option, failure to use the Plan’s PPO providers will result in a reduction of benefits. Click here for details on how to find participating providers in the Anthem Blue Cross PPO network (PDF).
Indemnity Dental Claim Forms
You rarely need to file a claim for dental benefits when you use Delta Dental providers. If forms are needed, ask your dentist to use the forms posted below:
Indemnity Dental Claim Form: Participant (PDF) | Retiree (PDF) | Supplemental Dental (PDF)
TBT Coordination of Benefits (COB) Questionnaire
If you or any of your eligible dependents have TBT medical benefits and are also covered by another group plan, the benefit payable by this Plan may be reduced. Benefit payments are coordinated between the plans so that you do not receive payment for more than 100% of the Usual, Customary and Reasonable (UCR) medical expenses for the covered treatment. The benefits payable under the Plan will not be greater than the actual amount that would have been paid if there were no other group plan involved.
Coordinated benefits cannot be determined and claims will NOT be paid until you complete the Coordination of Benefits (COB) Questionnaire (posted below) and return it to the TBT Plan Administration Office. If you have questions, please call 800-533-0119 and ask for the Claims Customer Service Unit.
A new Coordination of Benefits Questionnaire must be re-submitted every 12 months to TBT at the address shown on the form.
Coordination of Benefits Form: TBT COB Questionnaire (PDF)
HIPAA Privacy Disclosure Form
Click below to print the form needed to provide the TBT Plan Administration Office with your written permission to use or disclose specific health information:
TBT Authorization to Obtain and Disclose Personal Health Information (PDF)