Forms
These documents are in Adobe Reader format. If you do not have Adobe Reader, you can get it by clicking the icon below.
Health & Welfare Forms
Add/Delete Dependents Form
Use this form when you need to either add or remove dependents from the NCTI plan.
Health Plan Enrollment Form
This form should be used to enroll in the NCTI plan once you become eligible for coverage.
Authorization for Release of Protected Health Information
You can use this form to authorize the plan and administrator to release your protected health information (phi) to the individual/organization you designate.
Verification of Full-Time Student Status
Use this form to verify that your dependent child, who has reached the age of 19, is a full-time student at an accredited educational institution.
Request for Continued Coverage for Incapacitated Child
This form is required to be completed every two years if you have a dependent child who has reached the limiting age but continues to have coverage due to a mental or physical handicap.
Medical Claim Form
Use this form to obtain reimbursement for medical claims.
Dental Claim Form
Use this form when you receive covered dental services.
COBRA Election Form
This form is used to initiate continuous health coverage should you experience a COBRA qualifying event.
Retiree Health Application
Retirees should use this form to apply for Retiree Health and Welfare coverage.
Change of Beneficiary – Life Insurance
Use this form to change the beneficiary for your Life Insurance benefits.
Request for Treatment as an Assistance Eligible Individual
Complete this form if you wish to be considered an Assistance Eligible Individual and qualify for the COBRA subsidy.
Pension Forms
NCTI Defined Contribution Plan Application
Use this form to apply for your Defined Contribution Pension benefits if you are a participant in the
Northern California Tile Industry Defined Contribution Plan.
NCTI Defined Contribution Plan Eligible Rollover Distribution
This is a notice and election form for participants, surviving spouses and alternate payees regarding eligible rollover distributions from the
Northern California Tile Industry Defined Contribution Plan.
NCTI Defined Contribution Plan Eligible Rollover Distribution for non-Spouse Beneficiaries
This is a notice and election form for non-spouse beneficiaries regarding eligible rollover distributions from the
Northern California Tile Industry Defined Contribution Plan.
NCTI Defined Benefit Plan Eligible Rollover Distribution
This is a notice and election form for participants, surviving spouses and alternate payees regarding eligible rollover distributions from the
Northern California Tile Industry Defined Benefit Plan.
NCTI Defined Benefit Plan Eligible Rollover Distribution for non-Spouse Beneficiaries
This is a notice and election form for non-spouse beneficiaries regarding eligible rollover distributions from the
Northern California Tile Industry Defined Benefit Plan.
Your Rollover Options - IRS Tax Notice 2010
This is a notice regarding plan payments and rollovers.
NCTI Right to Defer Notice
This notice describes the provisions of the
Northern California Tile Industry Defined Contribution Plan that may affect your decision to defer distribution of your benefit.
Electronic Funds Transfer Form
Use this form if you wish to have your monthly pension payment deposited directly into your checking or savings account.
Tax Withholding Form
Payments from your pension plan are subject to federal and state income tax withholding. This form allows you to declare your tax withholding status.
Defined Benefit Plan Application Request
As you near retirement, you will want information about your retirement options. Use this form to request pre-retirement and benefit estimate information.
NCTI Hardship Withdrawal Application and Election Form
Use this form to apply for a hardship withdrawal from the
Northern California Tile Industry Defined Contribution Plan and to make a withholding election if you qualify for this withdrawal.
Change of Beneficiary Designation Form
Use this form to change your beneficiary for death benefits under the pension plans. Please note: if you are married, you must have your spouse's written and notarized approval to change your beneficiary to someone other than your spouse.
General Use Forms
Change of Information Form
Use this form to change your address or other information you have on file at Allied Administrators.