Download Forms & Applications

IBEW 76 / NECA Benefits Program

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**PLEASE NOTE** - ANY FORMS THAT YOU DOWNLOAD AND COMPLETE FROM THIS WEBSITE OR ANY OF THE LINKED WEBSITES MUST BE MAILED DIRECTLY TO:

EMPLOYEE BENEFIT ADMINISTRATORS, INC.
P.O. BOX 1747
DUVALL WA 98019

File name : Enrollment & Change Application

Use this form when enrolling for or making changes to benefits.

File name : Application for Trust-Paid Coverage During
Disability
Use this form for continuation of medical coverage during disability. See attached rules for details.

File name : Subsidized Retiree Health & Welfare Application

Use this form when enrolling for subsidized H&W benefits. Must be at least age 59. See attached rules for details.

File name : Application for Weekly Time Loss Disability
Benefits
Use this form for weekly time loss benefits during disability. See attached rules for details.

File name : Washington Dental Membership Application

Use this form for when enrolling in the Washington Dental Coverage Plan.

Important Links

First Choice Health Network
New York Life Benefit System
TPSC (Trusteed Plans)
TPSC Medical Claims Lookup
Washington Dental Service
Vision Service Plan
Group Health Cooperative
SAV- RX (Prescriptions)
IBEW Local 76
SW Washington NECA
IBEW National
NECA National