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Forms

When you need to enroll in a program, add a dependent, or file a claim,
just print the appropriate form, complete it as instructed, and then
mail it to the following address:

Los Angeles Machinist Benefit Trust
PO Box 6149 Garden Grove, CA 92846
Phone: (714) 898-2200
Toll Free: (800) 499-8121
Fax: (925) 405-0659


Make sure that you forward any required documentation along with your form.
If you are enrolling/adding a dependent due to marriage, a child's birth,
or an adoption, be sure to provide proof of dependency. A certified copy of
your marriage certificate, or a child’s birth certificate, or a court order showing
legal responsibility will be acceptable.

If you ever need assistance, feel free to contact the Administrative Office
at 323-278-7030 or 1-800-499-8121.

For Active Employees

Medical/Dental

Active Enrollment Form

Blue Shield Active Application Form

Special Enrollment Form for Children Dependents Age 9-25

Aetna Maternity Physician Statement Form

Behavioral Health Clinician Statement Form


Dental

Dental Benefit Comparison Charts—High, Medium, Low

Medical

Kaiser Enrollment Form

Blue Shield Application

Vision

VSP Enrollment Form

MES Enrollment Form

Disability Forms

Disability Form

Aetna Disability Form

Life Insurance Forms

Aetna Life Insurance Claim Form

Aetna Life Beneficiary Designation Form

For Retirees

Medical/Dental

Enrollment Form

Dental

Cigna Dental Enrollment Form

Dental Benefit Comparison Charts—High, Medium, Low

Medical

Blue Shield+65 Retiree Application

Behavioral Health Clinician Statement Form

Vision

MES Enrollment Form

VSP Enrollment Form