Active Sheet Metal Workers Packet Request Form The Sheet Metal Workers’ Health Plan of Southern California, Arizona & Nevada is now conducting its Annual Open Enrollment for eligible Active participants. If you wish to change your medical plan, now is the time to do so. More Details Eligible Active (Plan A and Plan B) Sheet Metal Workers Packet Request Form EmailThis field is for validation purposes and should be left unchanged.Name(Required) First Last Phone(Required)Email(Required) UID# or Last 4 digits of SSN(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is this a new address Check here if this is a new address I would like to receive and review detailed enrollment materials for:(Required)Make a selectionCaliforniaNevadaPlease send me enrollment materials for the following Medical Plan(s) available in the state of California.(Required) Fee-for-Service PPO Plan (Self-funded Indemnity) United HealthCare HMO Kaiser Permanente HMO Health Net HMO Please note that not all Plans are available in all areas. To enroll you must reside in the Plan’s covered service area, as defined by your zip code.Please send me enrollment materials for the following Medical Plan(s) available in the state of Nevada.(Required) Fee-for-Service PPO Plan (Self-funded Indemnity) United HealthCare of Nevada EPO Health Plan of Nevada HMO Hometown Health HMO (Northern Nevada only) Please note that not all Plans are available in all areas. To enroll you must reside in the Plan’s covered service area, as defined by your zip code.Your Dental Plan: If you are currently enrolled on the Delta PPO Plan and would like to receive a DeltaCare USA DMO packet for review, please check here. If you are currently enrolled on the Delta Care USA Plan and would like to receive a Delta PPO Plan packet for review, please check here. (only available to Plan A members) IMPORTANT- the Delta PPO plan has been reopened to eligible Plan A participants. If you are a Plan A participant enrolled in the DMO plan and fail to make an election during open enrollment, you will keep your current election and NOT be able to enroll in the PPO plan until next years open enrollment. Exceptions are only allowed for participants who do not reside within 30 miles of a contracted DMO dentist.Date MM slash DD slash YYYY Consent(Required) I understand that returning this form does not enroll me in a plan, or change my current plan.(Required)You must submit a completed Enrollment Form (included in each plan’s enrollment packet) for the plan of your choice, to the Administrative Office for any plan change to take effect.CAPTCHA Δ CA Plan Options Plan A Medical Summary Plan B Medical Summary Plan A Dental Summary NV Plan Options Plan A Medical Summary Plan B Medical Summary Plan A Dental Summary Online Request Form Complete the Online Form Downloadable Request Form(s) CA Packet Request Form (PDF) NV Packet Request Form (PDF)
