Enrollment Forms for Retirees
Your application for TBT retiree benefits cannot be processed until the TBT Plan Administration Office receives all required forms (as explained below).
Note: A self-pay contribution is also required under the Retirement Security Plan (RSP Silver), Basic Retiree Plan (BRP) or Comprehensive Retiree Plan (CRP). To avoid enrollment delays, send the first payment along with the Automated Direct Payment Form posted in the next section.
Follow these steps to complete the retiree enrollment process:
- Complete the Application for Retiree Benefits (All Retiree Plans) (PDF)
- Complete the Retiree Enrollment Form (All Retiree Plans) (PDF)
- Complete the Retiree Medical Option Form (RSP or CRP only) (PDF)
- Complete the RSP Dental Option Form (RSP only) (PDF)
- Complete an HMO Application Form (if choosing HMO option under CRP or RSP):
- Kaiser Enrollment/Change Form (Senior Advantage HMO): English (PDF)
- Anthem Blue Cross HMO Retiree Enrollment Form (HMO Plan for Non-Medicare Retirees) (PDF)
- Send your required forms, and a marriage certificate if you are married, to the TBT Plan Administration Office for receipt by the enrollment deadline:
MAIL to TBT Plan Administration Office, 39420 Liberty Street, Suite 260, Fremont, CA 94538-2200
Or FAX to (510) 795-9237
Or EMAIL to Retiree_COBRA@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.