Retirees Packet Request Form The Sheet Metal Workers’ Health Plan of Southern California, Arizona & Nevada is now conducting its Annual Open Enrollment for eligible Retired participants. If you wish to change your medical plan, now is the time to do so. More Details Retiree Packet Request Form (AZ, CA, NV) 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 selectionArizonaCaliforniaNevadaPlease send me enrollment materials for the following Medical Plan(s) available in the state of Arizona.(Required) United Healthcare EPO / Medicare Advantage HMO (available in specific zip codes only) Humana Medicare Advantage Nationwide PPO Plan (both participant and spouse must be enrolled in Medicare) 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 California.(Required) United Healthcare / Medicare Advantage Health Net / Seniority Plus Kaiser Permanente / Senior Advantage Humana Medicare Advantage Nationwide PPO Plan (both participant and spouse must be enrolled in Medicare) 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) United Healthcare EPO / Medicare Advantage HMO (Medicare Advantage is available in Southern Nevada only) Hometown Health (available in Northern Nevada only and is NOT available to individuals who are eligible for Medicare) Health Plan of Nevada / United Healthcare Group Medicare Advantage (available in both Northern and Southern Nevada) Humana Medicare Advantage Nationwide PPO Plan (both participant and spouse must be enrolled in Medicare) 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.Select one below(Required) I am eligible for and enrolled in Medicare Parts A and B I am not eligible for Medicare If you are married and have chosen “Retiree + Spouse” coverage, please also check one below: My spouse is eligible for and enrolled in Medicare Parts A and B My spouse is not eligible for Medicare 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 Plan Options AZ Retiree Plan Options CA Retiree Plan Options NV Retiree Plan Options Humana & Medicare Supplement Online Request Form Complete the Online Form Downloadable Request Form(s) AZ Packet Request Form (PDF) CA Packet Request Form (PDF) NV Packet Request Form (PDF) Medicare Supplement Packet Request Form (PDF)
