Enrollment Materials
The TBT Plan Administration Office automatically sends a new participant enrollment packet to you (at the address provided by your Employer when Plan contributions are sent to TBT on your behalf). If you need to enroll and have not yet received your enrollment materials, contact the TBT Plan Administration Office.
Enrollment for you and your eligible dependents is not automatic. If you don’t send in the required enrollment forms within 30 days after you and your covered dependents become eligible, the coverage may be delayed—or even denied if you choose an HMO.
For your convenience, TBT enrollment forms are posted below. Download the enrollment forms that apply to you, fill them out, and fax or mail to the TBT Plan Administration Office.
Enrollment Forms for Active Participants
Follow these steps to complete the enrollment process by your enrollment deadline (mentioned above):
- Complete the TBT Enrollment Form (PDF)
- Complete the TBT Medical Option Form (PDF)
- Complete the TBT Dental Option Form (PDF)
- Complete an HMO Application Form (if choosing a non-Medicare HMO option under your TBT Plan):
- Kaiser Enrollment Application: English (PDF) | Spanish (PDF)
- Anthem Blue Cross HMO (PDF)
- Send your TBT Enrollment Form, Medical Option Form, Dental Option Form, HMO application, birth or adoption certificates for all members of your family, and a marriage certificate if you are married, to the TBT Plan Administration Office.
Do not assume that you are enrolled in your new coverage until you receive confirmation.
MAIL to TBT Plan Administration Office, 39420 Liberty Street, Suite 260, Fremont, CA 94538-2200
Or FAX to (510) 795-9237
Or EMAIL to enroll@lipmantpa.com
REMINDERS
Don’t forget to fill in all sections and sign and date the forms before submitting them with the required legal documents. When sending by fax or email, call the TBT Plan Administration Office at (800) 533-0119 after a few days to confirm that your materials are received.
Extension of Benefits Disability Claim Form
If you are eligible but rendered unable to work because you become totally disabled as a result of an illness or injury, coverage for you and your covered dependents will continue for up to three months. Coverage is not automatic. You must apply for the extension of benefits by sending all the required forms and documentation to the TBT Plan Administration Office as requested. Call (800) 533-0119 and ask for the Disability Call Center as soon as your doctor determines that you will be out on disability.