Claim Form Rev 102012 213 385
User Manual: 213-385
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Page Count: 2
(i) A new claim form is required once every calendar year.
(ii) A new claim form is required for each new injury.
(iii) This Claim Form is necessary for the Fund to determine eligibility for benefits. All questions must
be answered or Claim Form will be returned. This form will NOT be valid unless signed in Part V.
Failure to complete and sign this form will delay the processing of your claim.
CLAIM
FORM
PART I : PARTICIPANT & SPOUSE INFORMATION
PARTICIPANT SPOUSE
(required whether or not spouse is patient)
NAME
First Last First Last
SSN or
PARTICIPANT ID
DATE OF
BIRTH mm/dd/yy mm/dd/yy
ADDRESS Street Street
City State Zip City State Zip
PHONE ( ) - ( ) -
EMPLOYER
NAME
EMPLOYER
ADDRESS
Street Street
City State Zip City State Zip
EMPLOYER
PHONE ( ) - ( ) -
PART II : PATIENT INFORMATION
NAME
First Last
ADDRESS
Street
City State Zip
PHONE ( ) -
RELATIONSHIP
TO
PARTICIPANT
( ) SELF
( ) SPOUSE
( ) DEPENDENT CHILD
PATIENT
GENDER
( ) MALE
( ) FEMALE
PATIENT MARITAL STATUS SINGLE MARRIED DIVORCED
Southern California Pipe Trades Administrative Corporation CLAIM FORM
Page 1 of 2 rev 102012
(SSN onlythe last four
digits required)
(if different from
above)
SOUTHERN CALIFORNIA PIPE TRADES
HEALTH & WELFARE FUND
(For Active Participants
& Eligible Dependents)
SOUTHERN CALIFORNIA PIPE TRADES
PENSIONERS & SURVIVING SPOUSES
HEALTH FUND
501 Shatto Place, 5th Fl., Los Angeles, CA 90020
(800) 595-7473 (213) 385-6161
Fax:(213) 487-3640 www.scptac.org
Printed
Is the patient eligible for other coverage or benefits? NO YES
PART III : OTHER COVERAGE or BENEFITS
If YES, please provide, type of coverage: Medical Dental Vision Others:_____________
NAME OF
POLICY HOLDER First Last
POLICY HOLDER
EMPLOYER
INFORMATION Name of policy holder Employer
POLICY
INFORMATION
Name of insurance group or plan number
( ) -
nalp ro puorg ecnarusni fo rebmuN enohPrebmuN tnuoccA yciloP
PART IV : CLAIM INFORMATION
This claim is being
submitted for:
PERIODIC SUBMISSION
every calendar year
(skip to PART V)
NEW NON-WORK RELATED
INJURY OR ILLNESS
(complete the following)
NEW WORK RELATED
INJURY OR ILLNESS
(complete the following)
DESCRIPTION
of Injury or Illness
HOW it occurred.
Describe sequence of
events and provide a
complete description of
Injury.
(include information of
other parties involved)
Attach additional pages if necessary.
WHERE
(address of location)
WHEN
(date & time)
PART V : AUTHORIZATION
I/We hereby certify that the foregoing statements, including any accompanying statements, are true, correct and complete to the best of my/our knowl-
edge. I/We hereby authorize the attending physician or any hospital to furnish and disclose to the Southern California Pipe Trades Health & Welfare Fund
or its agents all records and information concerning my physical condition that are within their possession or knowledge. I/We further authorize the Health
& Welfare Fund to use or disclose the information contained in its claim files in whatever way deemed necessary for the purpose of determining the rea-
sonableness of any of the expenses submitted herewith or the propriety of this claim. I/We also authorize any Union, Trust Fund, Employer or Insurance
Carrier to furnish the Southern California Pipe Trades Health & Welfare Fund with information regarding benefits to which I/we may be entitled.
XParticipant’s Signature Date
XPatient’s Signature (Not required if under 18 years of age) Date
(skip to
PART IV)
Southern California Pipe Trades Administrative Corporation CLAIM FORM
Page 2 of 2 rev 102012
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