Northern California Pipe Trades Trust Funds
for UA Local 342

935 Detroit Avenue, Suite 242A Concord, CA 94518-2501
Phone: 925/356-8921 | Fax: 925/356-8938 | E-Mail: tfo@ncpttf.com

SURVIVING DEPENDENT Enrollment / Change Form

Important:

For Kaiser Permanente and Blue Shield of California HMO Plans, there are limited coverage service areas within Northern California.

The Blue Shield of California HMO Plan is not available if any Surviving Dependents are eligible for Medicare.

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Blue Shield of California PPO and HMO / Kaiser Permanente HMO Surviving Dependent Enrollment / Change Form

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