Recent Plan Notices - CFAO | Carpenter Funds Administrative Office

ERISA - Plan A/R 1/13/2015 

CARPENTER FUNDS ADMINISTRATIVE OFFICE 

OF NORTHERN CALIFORNIA, INC. 

265 Hegenberger Road, Suite 100 ▪ P.O. Box 2280 

Oakland, California 94621 

(510) 633-0333 ▪ (888) 547-2054 

www.carpenterfunds.com 

October 18, 2010 

TO: 

FROM: 

RE: 

All Active Plan A, B and R Participants 

BOARD OF TRUSTEES 

Carpenters Health and Welfare Trust Fund for California 

Changes to Eligibility Rules and Disability Extension Filing Limit 

The Trustees have approved the following changes to the Health and Welfare Plan for Active Plan A, 

Plan B and Plan R Participants. 

‣ New Filing Limit for Disability Extension of Eligibility 

Effective for Disabilities that began on and after March 1, 2009 

The time limit for filing an application for a disability extension of eligibility has been increased 

from 6 months to 1 year. In order to qualify for the disability extension, you must send an 

application to the Fund Office no later than 1 year from the date of the onset of your disability. 

The disability extension is described in detail on pages 11 and 12 of the Plan A and Plan R 

benefit booklet and on page 11 of the Plan B benefit booklet. 

If you become disabled, you should obtain a Certificate of Disability form right away and mail the 

completed form to the Fund Office. You can call the Fund Office to request the form or visit the 

website at www.carpenterfunds.com and print a copy of the form. For purposes of determining 

the onset of disability, the Plan requires a statement from your attending physician verifying the 

beginning date of disability. 

‣ Maintaining Active Eligibility for Participants Receiving Mandatory Pension Payments 

Effective January 1, 2010 

If you are an Active Carpenter working in covered employment who is receiving mandatory 

pension payments from the Carpenters Pension Trust Fund because of reaching the Required 

Beginning Date, which is the April 1 st following the calendar year you turn 70½, you will continue 

to be eligible as an Active Participant provided you have not had a separation from service and 

you meet all other eligibility requirements. 

Please keep this notice with your benefit booklet. If you have any questions, please call Benefit 

Services at the Fund Office at (510) 633-0333 or toll free at (888) 547-2054. You may also send an 

e-mail to benefitservices@carpenterfunds.com. 

The Board of Trustees maintains the right to change or discontinue the types and amounts of 

benefits under this Plan. This notice is intended as a summary only, and actual Plan documents will 

be used to interpret the Plan. Only the full Board of Trustees is authorized to interpret the Plan. The 

Board has discretion to decide all questions about the Plan, including questions about your eligibility 

for benefits and the amount of any benefits payable to you. No individual Trustee, Employer or Union 

Representative has authority to interpret this Plan on behalf of the Board or to act as an agent of the 

Board.


This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection 

and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a 

grandfathered health plan can preserve certain basic health coverage that was already in effect when 

that law was enacted. 

Being a grandfathered health plan means that your plan may not include certain consumer protections 

of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of 

preventive health services without any cost sharing. However, grandfathered health plans must comply 

with certain other consumer protections in the Affordable Care Act, for example, the elimination of 

lifetime limits on benefits. 

Questions regarding which protections apply and which protections do not apply to a grandfathered 

health plan and what might cause a plan to change from grandfathered health plan status can be 

directed to the Trust Fund Office at the numbers listed above. You may also contact the Employee 

Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or 

www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not 

apply to grandfathered health plans. 

Active Participants in Plans A, B and R 2


June 20, 2011 



265 Hegenberger Road, Suite 100 P.O. Box 2280 

Oakland, California 94621-0180 

Tel. (510) 633-0333 (888) 547-2054 Fax (510) 633-0215 


TO: 

FROM: 

RE: 

All Active Plan A, B, Flat Rate and R Participants and their Dependents, including 

COBRA Beneficiaries 



BENEFIT IMPROVEMENTS 

Adult Child Coverage 

Removal of Lifetime Limit and 

Re-Enrollment for Individuals who have Exceeded the Lifetime Maximum 

Annual Limit Changes 

Early Retiree Reinsurance Program 

Attention Parents – this notice is being transmitted to you on behalf of your children 

Effective September 1, 2011, the Board of Trustees has approved modifications to the Plan Rules and 

Regulations for the Carpenters Health and Welfare Trust Fund for California which are explained in summary 

form below. In the event of a dispute between this summary notice and the Rules and Regulations of the Plan, 

the Rules and Regulations will prevail. 

In accordance with the Affordable Care Act (or “Health Care Reform”), the Plan is extending coverage for 

certain dependent children up to age 26, removing the overall lifetime dollar and specified annual maximums 

and adding an overall annual dollar maximum. 

1) Adult Child Coverage: Coverage for Participants’ adult natural, adopted or stepchildren age 19 up to the 

child’s 26 th birthday is offered starting September 1, 2011. Coverage will be provided to adult children 

who do not have access to group health coverage through their own, their spouse's, or their 

domestic partner’s employer. No action is required if you do not have an adult child to enroll, or if you 

choose not to enroll an adult child. If you elect to enroll an adult child, the child does not have to be 

unmarried, or be a full-time student, or even reside with the Participant in order to qualify for this extended 

coverage. 

Adult children whose coverage previously ended before their 26 th birthday, or who were denied coverage 

(or were not eligible for coverage) because the availability of dependent coverage ended before the 

attainment of age 26, may be eligible to enroll in the Plan during a Special Enrollment period*. This 

includes a child that is currently on COBRA continuation coverage. The Special Enrollment period ends 

July 31, 2011 for a September 1, 2011 coverage effective date. Any qualified children enrolled during this 

Special Enrollment opportunity will have all the same benefits that are available to similarly situated 

individuals, but in some cases will not have identical coverage as other dependent children. As stated 

above, adult children with access to employer sponsored health coverage through their own, their 

spouse's or domestic partner’s employer are not eligible to enroll. Also, certain mandated benefits required 

for minor children may not be available for adult children. 

Enclosed you will find the necessary form for enrollment. Complete the Enrollment Form and send in the 

required documentation of proof (see the back of the Enrollment Form for details). You must list all adult 

children to be enrolled in the "Adult Child Information" section. The Adult Child Special Enrollment Form 

must be returned to our office before July 31, 2011. If the enrollment form is not received by July 31, 

2011 but it is later determined that the adult child may be eligible to enroll at a later date, eligibility will be 

granted prospectively only, and will not be retroactive to September 1, 2011.


Note: *Coverage up to age 26 is only available if the adult child is the Participant’s natural child, legally 

adopted child or stepchild and the Participant is eligible for coverage and maintains eligibility. An adult 

child may not establish independent eligibility except as provided by COBRA. Legal guardianship children 

and children of domestic partners are not included in the age 26 extension. A child may not be enrolled in 

the Plan unless the Participant is also enrolled. If you, as the Participant, are eligible for coverage but not 

currently enrolled in the Plan, you also have the opportunity to enroll for coverage and must do so in order 

for your dependent child to be able to enroll, however, again if the Special Window is missed, Adult Child 

coverage will be granted beginning the 1 st of the month following enrollment and not retroactively. 

Since the Plan qualifies as a Grandfathered Plan under Health Care Reform, adult children are not 

eligible to enroll if they have access to health coverage through their employer or through their spouse's or 

domestic partner’s employer. In addition, any children of the dependent child (the Participant’s grandchild) 

will not be covered. 

The Plan will continue to provide coverage for disabled children of any age in accordance with the 

eligibility rules set out in the Plan Rules and Regulations. These rules extend coverage when the 

Participant’s unmarried Dependent children are incapable of self-sustaining employment by reason of a 

mental or physical handicap and such incapacity commenced prior to the date the Dependent child’s 

coverage would otherwise have terminated, and provided that the child is dependent upon the Eligible 

Participant for support and maintenance. 

2) Removal of Lifetime Limit: The Active Plans will no longer include overall lifetime benefit limits effective 

September 1, 2011. Plan lifetime maximum of $2,000,000 will be eliminated. 

Re-Enrollment for Individuals who have exceeded the Lifetime Maximum Benefit: Individuals whose 

coverage previously ended because they reached a lifetime limit under the Plan are eligible to re-enroll for 

benefit coverage under the Plan starting September 1, 2011. Please contact the Fund Office at 

benefitservices@carpenterfunds.com, call (510) 633-0333 or toll free (888) 547-2054 for an Enrollment 

Form. 

3) Annual Limit Changes: Beginning September 1, 2011, a calendar year annual overall maximum of 

$2,000,000 will be added to Active Indemnity Plans for all Medical and Prescription Drug benefits paid for 

each Eligible Individual. 

On September 1, 2011, Active Plans will remove the following calendar year maximums and will no longer 

have specific benefit limits: 

Chemical Dependency inpatient and outpatient treatment calendar year maximum of $25,000 

and lifetime maximum of $35,000. 

Pediatric Dental $2,500 (or $2,000 for Non-PPO dentists) calendar year maximum for children 

under age 19. 

Prescription Drug benefit limit of $75,000 per Eligible Individual per calendar year. 

Routine Physical Examination maximum payment limit of $250 for the Participant and Spouse. 

Diabetes Instruction Program lifetime limit of $500 per Eligible Individual. 

Hospice Care maximum Plan payment of $5,000 per Eligible Individual. 

Low Vision Benefit maximum benefit of $500 per person for children under age 19. 

4) Notice to Plan Participants about the Early Retiree Reinsurance Program: You are a Plan 

Participant, or are being offered the opportunity to enroll as a Plan Participant, in an employment-based 

health plan that is certified for participation in the Early Retiree Reinsurance Program. The Early Retiree 

Reinsurance Program is a Federal program that was established under the Affordable Care Act. Under the 

Early Retiree Reinsurance Program, the Federal government reimburses a Plan Sponsor of an 

employment-based health plan for some of the costs of health care benefits paid on behalf of, or by, early 

retirees and certain family members of early retirees participating in the employment-based plan. By law, 

the program expires on January 1, 2014. 

2


Under the Early Retiree Reinsurance Program, your Plan Sponsor may choose to use any 

reimbursements it receives from this program to reduce or offset increases in Plan Participants’ premium 

contributions, co-payments, deductibles, co-insurance, or other out-of-pocket costs. If the Plan Sponsor 

chooses to use the Early Retiree Reinsurance Program reimbursements in this way, you, as a Plan 

Participant, may experience changes that may be advantageous to you, in your health plan coverage 

terms and conditions, for so long as the reimbursements under this program are available and this Plan 

Sponsor chooses to use the reimbursements for this purpose. A Plan Sponsor may also use the Early 

Retiree Reinsurance Program reimbursements to reduce or offset increases in its own costs for 

maintaining your health benefits coverage, which may increase the likelihood that it will continue to offer 

health benefits coverage to its retirees and employees and their families. 

Grandfathered Health Plan: The Board of Trustees of the Carpenters Health and Welfare Trust Fund for 

California believes this Plan is a “grandfathered health plan” under the Patient Protection and Affordable Care 

Act (“the Affordable Care Act”). As permitted by the Affordable Care Act, a grandfathered health plan can 

preserve certain basic health coverage that was already in effect when that law was enacted. Being a 

grandfathered health plan means that your Plan may not include certain consumer protections of the 

Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventative 

health services without any cost sharing. However, grandfathered health plans must comply with certain other 

consumer protections in the Affordable Care Act, for example the elimination of lifetime limits on benefits. 

Questions regarding which protections apply and which protections do not apply to a grandfathered health 

plan and what might cause a plan to change from grandfathered health plan status can be directed to the Plan 

administrator or the Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This Web site 

has a table summarizing which protections do and do not apply to grandfathered health plans. 

Please keep this notice with your benefit booklet. If you have any questions, please contact Benefit Services 

at the Fund Office at (510) 633-0333 or toll free at (888) 547-2054. You may also send an e-mail to 

benefitservices@carpenterfunds.com. Forms and information can be found on our website at 

www.carpenterfunds.com. 

The Board of Trustees maintains the right to change or discontinue the types and amounts of benefits under 

this Plan. This notice is intended as a summary only, and actual Plan documents will be used to interpret the 

Plan. Only the full Board of Trustees is authorized to interpret the Plan. The Board has discretion to decide all 

questions about the Plan, including questions about your eligibility for benefits and the amount of any benefits 

payable to you. No individual Trustee, Employer or Union Representative has authority to interpret this Plan on 

behalf of the Board or to act as an agent of the Board. 

In accordance with ERISA reporting requirements this document serves as your Summary of Material 

Modifications to the Plan. 

3


HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) 

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION (PHI) 

Carpenters Health and Welfare Trust Fund for California: Notice of Privacy Practices 

Esta noticia es disponible en espanol si usted lo suplica. Por favor contacte el Funcionario de Privacidad (510-639-4301). 

CARPENTERS HEALTH AND WELFARE 

TRUST FUND FOR CALIFORNIA 

Notice of Privacy Practices 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU 

MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO 

THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

In this notice, the name “Carpenters Health and Welfare Fund” and the terms “we”, “us”, and “our” 

encompass not only this health plan itself but also Business Associates acting on behalf of the plan or 

providing services to the plan. These Business Associates may include a third party administrator, a 

pharmacy benefits manager, and professionals such as attorneys, auditors, and consultants. It does not 

include the Board of Trustees, the Plan Sponsor, which will be specified where appropriate. 

DUTIES OF CARPENTERS HEALTH AND WELFARE FUND 

We are required by law to maintain the privacy of your health information. We must provide you with 

this Notice of our legal duties and privacy practices with respect to your health information, we are 

required to notify you if there is a breach of your unsecured protected health information, and we are also 

required to abide by the terms of this Notice, which may be amended from time to time. 

We reserve the right to change the terms of this Notice at any time in the future and to make the new 

provisions effective for all health information that we maintain. We will promptly revise our Notice and 

distribute it to all Plan Participants whenever we make material changes to our privacy policies and 

procedures within 60 days of such change. This Notice will also be provided to all new enrollees as 

required. 

HOW CARPENTERS HEALTH AND WELFARE FUND MAY USE OR DISCLOSE 

YOUR HEALTH INFORMATION 

We are permitted by law to use or disclose your “health information” to conduct activities necessary for 

“payment” and “health care operations” (as those terms are defined in the attached Glossary). These are 

the main purposes for which we will use or disclose your health information. For each of these purposes 

we list below examples of these kinds of uses and disclosures. These are only examples and are not 

intended to be a complete list of all the ways we may use or disclose your health information. 

Payment. We may use or disclose health information about you for purposes within the definition of 

“payment”. These include, but are not limited to, the following purposes and example: 

Determining your eligibility for plan benefits. For example, we may use information obtained from 

your employer to determine whether you have satisfied the plan’s requirements for active eligibility. 

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Obtaining contributions from you or your employer. For example, we may send your employer a 

request for payment of contributions on your behalf, and we may send you information about 

premiums for COBRA continuation coverage. 

Pre-certifying or pre-authorizing health care services. For example, we may consider a request 

from you or your physician to verify coverage for a specific hospital admission or surgical procedure. 

Determining and fulfilling the plan’s responsibility for benefits. For example, we may review 

health care claims to determine if specific services that were provided by your physician are covered 

by the plan. 

Providing reimbursement for the treatment and services you received from health care 

providers. For example, we may send your physician a payment with an explanation of how the 

amount of the payment was determined. 

Subrogating health claim benefits for which a third party is liable. For example, we may 

exchange information about an accidental injury with your attorney who is pursuing reimbursement 

from another party. 

Coordinating benefits with other plans under which you have health coverage. For example, we 

may disclose information about your plan benefits to another group health plan in which you 

participate. 

Obtaining payment under a contract of reinsurance. For example, if the total amount of your 

claims exceeds a certain amount we may disclose information about your claims to our stop-loss 

insurance carrier. 

Health Care Operations. We may use and disclose health information about you for purposes within the 

definition of “health care operations”. These purposes include, but are not limited to: 

Conducting quality assessment and improvement activities. For example, a supervisor or quality 

specialist may review health care claims to determine the accuracy of a processor’s work. 

Case management and care coordination. For example, a case manager may contact home health 

agencies to determine their ability to provide the specific services you need. 

Contacting you regarding treatment alternatives or other benefits and services that may be of 

interest to you. For example, a case manager may contact you to give you information about 

alternative treatments which are neither included nor excluded in the plan’s documentation of benefits 

but which may nevertheless be available in your situation. 

Contacting health care providers with information about treatment alternatives. For example, a 

case manager may contact your physician to discuss moving you from an acute care facility to a more 

appropriate care setting. 

Employee training. For example, training of new claims processors may include processing of 

claims for health benefits under close supervision. 

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Accreditation, certification, licensing, or credentialing activities. For example, a company that 

provides professional services to the plan may disclose your health information to an auditor that is 

determining or verifying its compliance with standards for professional accreditation. 

Securing or placing a contract for reinsurance of risk relating to claims for health care. For 

example, your demographic information (such as age and sex) may be disclosed to carriers of stop 

loss insurance to obtain premium quotes. 

Conducting or arranging for legal and auditing services. For example, your health information 

may be disclosed to an auditor who is auditing the accuracy of claim adjudications. 

Management activities relating to compliance with privacy regulations. For example, the Privacy 

Officer may use your health information while investigating a complaint regarding a reported or 

suspected violation of your privacy. 

Resolution of internal grievances. For example, your health information may be used in the process 

of settling a dispute about whether or not a violation of our privacy policies and procedures actually 

occurred. 

Disclosures to Plan Sponsor (Board of Trustees). In addition to the circumstances and examples 

described above, there are three types of health information about you that we may disclose to the Board 

of Trustees. The disclosures described below are included within the definitions of “payment” or “health 

care operations”. 

We may disclose to the Board of Trustees whether or not you have enrolled in, are participating in, or 

have disenrolled from this health plan. 

We may provide the Board of Trustees with “summary health information”, which includes claims 

totals without any personal identification except your ZIP code, for these two purposes: 

- To obtain health insurance premium bids from other health plans, or 

- To consider modifying, amending, or terminating the health plan. 

We may disclose your health information to the Board of Trustees for purposes of administering 

benefits under the plan. These purposes may include, but are not limited to: 

- Reviewing and making determinations regarding an appeal of a denial or reduction of benefits. 

- Evaluating situations involving suspected or actual fraudulent claims. 

- Monitoring benefit claims that may or do involve stop-loss insurance. 

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Other Uses and Disclosures. The following categories describe other ways that Carpenters Health and 

Welfare Fund may use and disclose your health information. Each category is illustrated with one or 

more examples. Not every potential use or disclosure in each category will be listed, and those that are 

listed may never actually occur. 

Involvement in Payment. With your agreement, we may disclose your health information to a 

relative, friend, or other person designated by you as being involved in payment for your health care. 

For example, if we are discussing your health benefits with you, and you wish to include your spouse 

or child in the conversation, we may disclose information to that person during the course of the 

conversation. 

Required by Law. We will disclose your health information when required to do so by Federal, 

state, or local law. For example, we may disclose your information to a representative of the U.S. 

Department of Health and Human Services who is conducting a privacy regulations compliance 

review. 

Public Health. As permitted by law, we may disclose your health information as described below: 

- To an authorized public health authority, for purposes of preventing or controlling disease, injury 

or disability; 

- To a government entity authorized to receive reports of child abuse or neglect; 

- To a person under the jurisdiction of the Food and Drug Administration, for activities related 

to the quality, safety, or effectiveness of FDA-regulated products. 

Health Oversight Activities. We may disclose your health information to health agencies during the 

course of audits, investigations, inspections, licensure and other proceedings related to oversight of 

the health care system or compliance with civil rights laws. However, this permission to disclose your 

health information does not apply to any investigation of you which is directly related to your health 

care. 

Judicial and Administrative Proceedings. We may disclose your health information in the course 

of any administrative or judicial proceeding: 

- In response to an order of a court or administrative tribunal, or 

- In response to a subpoena, discovery request, or other lawful process. 

Specific circumstances may require us to make reasonable efforts to notify you about the request or to 

obtain a court order protecting your health information. 

Law Enforcement. We may disclose your health information to a law enforcement official for 

various purposes, such as identifying or locating a suspect, fugitive, material witness or missing 

person. 

Coroners, Medical Examiners and Funeral Directors. We may disclose your health information to 

coroners, medical examiners and funeral directors. For example, this may be necessary to identify a 

deceased person or determine the cause of death. 

Organ and Tissue Donation. We may disclose your health information to organizations involved in 

procuring, banking or transplanting organs and tissues, to facilitate such. 

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WHEN CARPENTERS HEALTH AND WELFARE FUND MAY NOT USE OR 

DISCLOSE YOUR HEALTH INFORMATION 

Except as described in this Notice of Privacy Practices, we will not use or disclose your health 

information without written authorization from you. Specifically, most uses and disclosures of your 

psychotherapy notes (where appropriate), uses and disclosures of your protected health information for 

marketing purposes, and disclosures that constitute a sale of your protected health information require 

your written authorization. If you have authorized us to use or disclose your health information for 

another purpose, you may revoke your authorization in writing at any time. If you revoke your 

authorization, we will no longer be able to use or disclose health information about you for the reasons 

covered by your written authorization. However, we will be unable to take back any disclosures we have 

already made with your permission. Requests to revoke a prior authorization must be submitted in 

writing to the Privacy Officer at the address shown below. 

The Carpenters Health and Welfare Fund will not use or disclose your genetic health information for 

underwriting purposes. Additionally, you have the right to opt out of receiving any communications 

concerning fund raising activities in which the Carpenters Health and Welfare Fund may engage. 

Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures 

of your health information. We are not required to agree to restrictions that you request except if the 

disclosure involves payment or health care operations not required by law and the information pertains 

solely to a health care item or service that you have paid for out of pocket in full. If you would like to 

make a request for restrictions, you must submit your request in writing to the Privacy Officer at the 

address shown below. 

Right to Request Confidential Communications. You have the right to ask us to communicate with 

you using an alternative means or at an alternative location. Requests for confidential communications 

must be submitted in writing to the Privacy Officer at the address shown below. We are not required to 

agree to your request unless disclosure of your health information could endanger you. 

Right to Inspect and Copy. You have the right to inspect and copy health information about you that 

may be used to make decisions about your plan benefits. To inspect or copy such information, you must 

submit your request in writing to the Privacy Officer at the address shown below. If you request a copy of 

the information, we may charge you a reasonable fee to cover expenses associated with your request. 

Right to Request Amendment. If you believe that we possess health information about you that is 

incorrect or incomplete, you have a right to ask us to change it. To request an amendment of health 

records, you must make your request in writing to the Privacy Officer at the address shown below. Your 

request must include a reason for the request. We are not required to change your health information. If 

your request is denied, we will provide you with information about our denial and how you can disagree 

with the denial. 

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Right to Accounting of Disclosures. You have the right to receive a list or “accounting” of disclosures 

of your health information made by us. However, we do not have to account for disclosures that were: 

made to you or were authorized by you, or 

for purposes of payment functions or health care operations. 

Requests for an accounting of disclosures must be submitted in writing to the Privacy Officer at the 

address shown below. Your request should specify a time period within the last six years and may not 

include dates before April 14, 2003. We will provide one free list per twelve-month period, but we may 

charge you for additional lists. 

Right to Paper Copy. You have a right to receive a paper copy of this Notice of Privacy Practices at any 

time. To obtain a paper copy of this Notice, send your written request to the Privacy Officer at the 

address shown below or you can download a copy at www.carpenterfunds.com. 

Your Personal Representative 

You may exercise your rights to your PHI by designating a personal representative. Your personal 

representative will be required to produce evidence of the authority to act on your behalf before the 

personal representative will be given access to your PHI or be allowed to take any action for you. Under 

this Plan, proof of such authority will include a completed, signed and approved form. You may obtain 

this form by contacting the Privacy Officer or his or her designee at their address listed on the first page of 

this Notice. The Plan retains discretion to deny access to your PHI to a personal representative to provide 

protection to those vulnerable people who depend on others to exercise their rights under these rules and 

who may be subject to abuse or neglect. 

This Plan will recognize certain individuals as Personal Representatives without you having to complete 

a Personal Representative form. You may however request that the Plan not automatically honor the 

following individuals as your Personal Representative by completing a form to Revoke a Personal 

Representative available from the Privacy Officer or their designee. 

For example, the Plan will automatically consider a spouse to be the personal representative of a Plan 

Participant and vice versa. The recognition of your spouse as your personal representative (and vice 

versa) is for the use and disclosure of PHI under this Plan and is not intended to expand such 

designation beyond what is necessary for this Plan to comply with HIPAA privacy regulations. You 

should also review the Plan’s Policy and Procedure regarding Personal Representatives (available 

from the Privacy Officer) for a more complete description of the circumstances where the Plan will 

automatically consider an individual to be a personal representative. 

If you would like to obtain a more detailed explanation of these rights, or if you would like to exercise 

one or more of these rights, contact: 

HIPAA Privacy Officer 


P.O. Box 2280 

Oakland, CA 94621-0181 

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Complaints. If you believe that your privacy rights have been violated by Carpenters Health and Welfare 

Trust Fund for California, or by anyone acting on our behalf, you may file a complaint. Complaints to us 

must be submitted in writing to the Privacy Officer at the above address. You may also file a complaint 

with the Secretary of the Department of Health and Human Services at: 

200 Independence Avenue, SW 

Washington, DC 20201 

We will not retaliate against you in any way for filing a complaint. 

Questions. If you have questions about any part of this Notice or if you want more information about the 

privacy practices at Carpenters Health and Welfare Fund, please contact the Privacy Officer at the above 

address. 

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CARPENTERS HEALTH AND WELFARE TRUST FUND 

FOR CALIFORNIA 

265 Hegenberger Road, Suite 100 

P.O. Box 2280 


Tel. (510) 633-0333 (888) 547-2054 Fax (510) 633-0215 


November 8, 2013 

To: 

From: 

Re: 

All Active and Retired Participants of the Carpenters Health and Welfare Trust Fund for California 



Medical and Prescription Drug Plan Benefit Changes Effective January 1, 2014 (Indemnity Plan Only) 

Service Pension Retiree Health and Welfare Window Period Closes on August 31, 2013 

Effective January 1, 2014, the Board of Trustees have adopted the following two changes to the Indemnity Medical 

and Prescription Drug plans only. 

1) CT Scans and MRIs 

Imaging services such as CT scans and MRIs give you and your doctor a valuable look at the inside of your 

body. These services can fluctuate in cost from as little as $300 to as much as $3,000* without quality 

differences. Therefore, if your doctor refers you to an imaging provider for a CT scan or MRI, your referral will 

be reviewed to see if the imaging provider selected offers the best quality of care and price in your area. If it 

doesn’t, starting January 1, 2014, a representative from Anthem Blue Cross will call you and let you know of 

other imaging provider choices close by. While the choice to choose the more expensive option will be yours, 

your personal share of costs will increase. We strongly recommend accepting Anthem’s recommendation to a 

high quality, lower cost provider. 

*Source: AIM Specialty Health internal cost analysis 

2) New Rules for Proton Pump Inhibitors (PPIs), Opiates, Antidepressants, Antipsychotics, and Stimulants 

To ensure the health safety of Plan Participants and Dependents, enhanced Plan coverage rules have been 

adopted for stomach acid reducing medications, known as Proton Pump Inhibitors (PPIs), and opiate pain 

medications like Vicodin, or Oxycodone. Effective January 1, 2014, unless clinical documentation verifies a 

longer duration is medically necessary, a course of treatment for PPIs will be limited to a maximum of eight (8) 

weeks and a course of treatment for opiates will be limited to a maximum of 90 days. The Plan also adopted 

changes effective January 1, 2014 for Antidepressants, Antipsychotics, and Stimulants, including mandatory 

generics for new starts, step therapy programs, and prior authorization rules. 

Retiree Health and Welfare – Out of Work Special Window Period Closed 

Service Type Pension 

Beginning September 2010 a window period of time was created for Retirees awarded a Service Pension from the 

Carpenters Pension Trust Fund for Northern California and whose last work was in covered employment for a 

Contributing Employer so that the “hours in covered employment” requirements for Retiree Health and Welfare 

eligibility could be satisfied by proof that he or she was on the “out-of-work” list at a Local Union affiliated with the 

Carpenters 46 Northern California Counties Conference Board. On August 31, 2013 that window period of time was 

closed and all Pensioners must satisfy “hours in covered employment” primarily through work hours.


GRANDFATHERED HEALTH PLAN: 

The Board of Trustees of the Carpenters Health and Welfare Trust Fund for California believes the Medical Plan is a 

“grandfathered health plan” under the Patient Protection and Affordable Care Act (“the Affordable Care Act”). As 

permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that 

was already in effect when that law was enacted. Being a grandfathered health plan means that your Plan may not 

include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the 

requirement for the provision of preventative health services without any cost sharing. However, grandfathered health 

plans must comply with certain other consumer protections in the Affordable Care Act, for example the elimination of 

lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a 

grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be 

directed to the Plan administrator or the Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. 

This website has a table summarizing which protections do and do not apply to grandfathered health plans. Please 

keep this notice with your benefit booklet. If you have any questions, please contact Benefit Services at the Fund 

Office at (510) 633-0333 or toll free at (888) 547-2054. You may also send an e-mail to 

benefitservices@carpenterfunds.com. Forms and information can be found on our website at 


The Trustees work diligently to protect your Plan and access to your Plan and only the Board of Trustees maintains 

the right to change or discontinue the types and amounts of benefits under this Plan. This notice is intended as a 

summary only, and actual Plan documents will be used to interpret the Plan. Only the full Board of Trustees is 

authorized to interpret the Plan. The Board has discretion to decide all questions about the Plan, including questions 

about your eligibility for benefits and the amount of any benefits payable to you. No individual Trustee, Employer or 

Union Representative has authority to interpret this Plan on behalf of the Board or to act as an agent of the Board. In 

the event of a dispute between this summary notice and the Rules and Regulations of the Plan, the Rules and 

Regulations will prevail.






(510) 633-0333 ▪ (888) 547-2054 


November 25, 2013 

MEMORANDUM 

TO: 

FROM: 

RE: 

Retirees of the 

Carpenters Pension Trust Fund for Northern California 

Carpenters Annuity Trust Fund for Northern California 

Boards of Trustees 

Post-Retirement Prohibited Employment 

Restated Clarification of Policy of Prohibited Employment Guidelines 

The Trustees of the Carpenters Pension Trust Fund for Northern California and the Carpenters Annuity Trust Fund for 

Northern California recognize that from time to time Retirees may be required to supplement Retiree income through 

post-retirement employment. However, so that active non-retired Participants may continue to earn retirement benefits, 

Prohibited Employment rules have been part of the retirement Plans since inception. 

The purpose of “Prohibited Employment” is to help individuals comply with IRS separation from service requirements and 

discourage Retirees already receiving a Pension from the Carpenters Pension Trust Fund for Northern California and/or 

the Carpenters Annuity Trust Fund for Northern California, from engaging in activities that adversely affect the ability of 

other Plan Participants to accumulate benefits under the Northern California Carpenters’ Pension and/or Annuity Funds. 

In June 2009, Trustees of the Carpenters Pension and Annuity Trust Funds approved a Special Temporary Window 

Period through August 31, 2011 in which post-retirement employment Prohibited Employment rules were temporarily 

modified. In 2011 the window was extended through December 31, 2013. Recently the Boards of Trustees adopted 

Restated Clarification of Policy of Prohibited Employment Guidelines with no sunset provisions. Therefore, when 

considering if post-retirement employment will result in the suspension of an individual’s Pension payments, the following 

rules will be used: 

Prohibited Employment means employment after retirement for wages or profit in the Building and Construction Industry 

that will result in the suspension of retirement benefits. The determination as to whether or not a type of employment is 

Prohibited shall be at the sole discretion of the Boards of Trustees. 

Whether post-retirement employment is Prohibited, or not, will depend on which of the following three categories the job 

falls: 

1. Non-Prohibited Employment outside the Building and Construction Industry 

2. Non-Prohibited Employment within the Building and Construction Industry 

3. Prohibited Employment within the Building and Construction Industry that will result in the suspension 

of benefit payments 

With the division of employment into these three categories many post-retirement work opportunities are allowed for 

Retirees receiving monthly payments. However, many jobs which involve a type of work covered by the Collective 

Bargaining Agreement in Northern California are still Prohibited and will result in the suspension of benefit payments. 

Whether or not a job will result in the suspension of benefit payments is subject to Trustee interpretation. Only the full 

Board of Trustees is authorized to interpret the Pension and/or Annuity Plans and any conflict between this 

notice and Plan documents will be resolved in favor of the Plan documents.


March 1, 2014 





(510) 633-0333 ▪ (888) 547-2054 


RE: 



Income Tax Withholding 

Dear Retiree/Beneficiary: 

As a reminder, you may choose the number of withholding allowances used to determine how much 

Federal Income Tax is withheld from your retirement payments. You may also elect to have no 

withholding. 

If your monthly Retirement Payments are less than $1,680 per month in 2014 

We will not automatically withhold taxes 

You may elect withholding if you like 

If you previously requested withholding, we will continue to withhold taxes 

If your monthly Retirement Payments are greater than $1,680 per month in 2014 

We will automatically withhold taxes assuming "Married, 3 exemptions" (IRS requirement) 

However, you may elect withholding based on the following: 

A different marital status, and/or 

A different number of exemptions, or 

No withholding at all 

If you previously requested withholding, we will continue to withhold taxes 

The 2013 rate was also $1,680 and remains the same in 2014. If you wish to change your income tax 

deductions you must submit a new Form W-4P Withholding Certificate for Pension or Annuity 

Payments. To obtain a W-4P withholding form: 

• Contact the Fund Office Benefit Services Department 

Phone: (510) 633-0333 or Toll Free at (888) 547-2054 

Email: benefitservices@carpenterfunds.com 

Visit: www.carpenterfunds.com/par_downloads.html 

• Visit the Internal Revenue Service’s website: www.irs.gov 

If you request a change, it will be put into effect within 60 days after receipt of the form. 

Withholding is one way for you to pay a portion of your income tax. If no tax, or not enough tax, 

is withheld from your benefits, you may have to pay estimated taxes during the year or a tax 

penalty at the end of the year. Of course, whether you have to pay federal income tax on your 

benefit payments depends on the total amount of your taxable income. Your decision on 

withholding is an important one, and you may wish to discuss it with a qualified tax adviser. 

Sincerely, 

BOARD OF TRUSTEES


June 13, 2014 

CARPENTERS PENSION TRUST FUND 

FOR NORTHERN CALIFORNIA 



Tel. (510) 633-0333 (888) 547-2054 Fax (510) 633-0215 


TO: 

FROM: 

RE: 

All Participants, Beneficiaries, Participating Local Unions, and Contributing Employers 

Board of Trustees 


Notice of Reduction in Future Accruals 

Effective July 1, 2014, the Collective Bargaining Agreement provides for increases in the Contributions paid into 

the Carpenters Health and Welfare and Pension Trust Funds. We have been advised that of the new money 

earmarked for benefits, $0.50 is to be allocated to Health and Welfare and $0.35 to Pension. These increases 

will not reduce wages. Even though many Employers are already party to the extended agreement, those 

Employers who do not sign the new extended agreement prior to July 1, 2014, pay an additional $0.75 per hour 

that will be allocated to Pension “off benefit”. The additional $0.75 will be applied to general Pension liabilities 

and will not be reflected on individual Participant Pension Statements. Those employees working for nonextended 

employers will be credited in the same manner and at the same contribution rates as employees 

working for extended employers. 

Even though the Scheduled Contribution Rate for Pension is increasing, in order to keep the Monthly Benefit at 

approximately the same amount each year, the Accrual Rate Percentage of Contribution Factor will continue to 

decrease. The new money is intended to increase the financial stability of the Pension Fund by paying more 

towards unfunded liabilities. The same number of Hours in Covered Employment will continue to earn 

approximately the same dollar value benefit each year. 

These changes do not affect benefits earned prior to July 2014. If you are currently retired and receiving a 

monthly benefit payment from the Pension Fund, your payments will continue uninterrupted. 

Effective Date 

Scheduled 

Contribution 

Rate 

Accrual Rate 

Percentage of 

Contribution Factor 

Monthly Benefit, 

Assuming 1,740 Hours 

(Sample) 

July 1, 2014 to June 30, 2015 $9.20 1.31% $209.70 

July 1, 2015 to June 30, 2016 $9.35 1.29% $209.87 

July 1, 2016 to June 30, 2017 $9.50 1.27% $209.93 

July 1, 2017 to June 30, 2018 $9.65 1.25% $209.89 

Starting July 1, 2018 $9.80 1.23% $209.74 

For more information about this notice or the Pension Plan in general, please contact the Trust Fund Office at: 

Carpenter Funds Administrative Office of Northern California, Inc. 

P.O. Box 2280 


Toll-Free: (888) 547-2054 or (510) 633-0333 


benefitservices@carpenterfunds.com 

Only the full Board of Trustees is authorized to interpret the Pension Plan. The Board has discretion to decide 

all questions about the Plan, including questions about your eligibility for benefits and the amount of any benefits 

payable to you. Plan rules and benefits may change from time to time. If this occurs, a written notice will be 

issued explaining the change. Please be sure to read all Plan communications and keep information about 

changes with your Plan booklet.


June 2014 

To: 

From: 

Re: 

All Eligible Employees 



265 Hegenberger Road Suite 100- P.O. Box 2280 


(510) 633-0333- (888) 547-2054 



Northern California Carpenters 401 (k) Plan (the "Plan") 

IMPORTANT INFORMATION REGARDING 

THE NORTHERN CALIFORNIA CARPENTERS 401 (k) PLAN 

The following information is required by law to be provided on an annual basis to all participants and employees 

eligible to participate in the Plan. 

Please read this notice carefully, as it contains important information about certain features of your Plan. To 

obtain more general information about the Plan, you should obtain a copy of the Plan's Summary Plan 

Description ("SPDj. See "FOR ADDITIONAL INFORMATION," beiON, for information on how you can obtain a 

copy of the Plan's current SPD. 

NOTE: 

Many of your Plan elections are made by contacting New York Life Retirement Plan Services ("New 

York Life"). If you need to contact New York Life, you may do so: 

• 24 hours a day via the internet at www.mylife.newyorklife.com, or by calling New York Life's 

automated telephone system at: (800) 294-3575. To speak with a Service Representative, call 

(800) 294-3575 between 8:00AM to 1 O:OOPM Eastern. 

• For advisory help you may contact Pensionmark Retirement Group at www.pensionmark.com or by 

calling (888) 201-5488 between 8:30AM to 5:00PM Pacific Time. 

Enroll in the Northern California Carpenters 401(k) Plan today! Complete an Enrollment/Contribution Change 

Form indicating the hourly amount you wish to defer and return it to your employer to begin payroll contributions. 

The enrollment form is available on-line at www.carpenterfunds.com. 

IRS SAFE-HARBOR NOTICE - 2014 PLAN YEAR 

This notice is designed to inform participants of their related rights and obligations under the Plan, and satisfy the 

requirements of the final regulations under Internal Revenue Code Sections 401 (k) and 401 (m). 

Safe Harbor Non-Elective Contribution- 2014 Plan Year 

If you are an elig!ble participant under the Plan, your employer will make a contribution on your behalf equal to at 

least 3% of your pay to either the Carpenters Annuity Trust Fund for Northern California or to the Northern 

California Carpenters 401 (k) Plan as follows: 

• If you are a collectively bargained employee, you will receive an employer contribution to theCarpenters 

Annuity Trust Fund for Northern California equal to at least 3% of your pay. 

• If you are a non-collectively bargained employee, your employer will make a contribution to the Northern 

California Carpenters 401(k) Plan on your behalf equal to 3o/oof your pay. 

For Example: Assume you are paid $30,000 for the Plan Year. Your employer will contribute at least $900 (3% x 

$30,000) for the Plan Year, whether or not you elect to make any deferred contributions to the Plan. 

NOTE: If you are a collectively bargained employee participating in the Carpenters Annuity Trust Fund for 

Northern California, the employer contribution you receive under that Plan for the Plan Year will 

be treated as your Safe Harbor Non-Elective Contribution for purposes of this Plan - provided it equals 

at least 3% of your pay for the Plan Year. You will not receive an additional three percent (3%) 

contribution to the Northern California Carpenters 401(k) Plan.


Other Employer Contributions 

No additional employer contributions will be made under the Plan. 

Type and Amount of Compensation that May Be Deferred 

As a participant in the Plan, you may elect to defer a portion of your pay each Plan Year. Your employer will 

contribute this amount (your "deferral contributions") tothe Plan. 

You may make either regular 401 (k) deferrals (pre-tax) or Roth 401 (k) deferrals (after-tax). Your election 

regarding the amount and type of deferrals is irrevocable with respect to any deferrals already withheld from your 

pay. If you make regular 401 (k) deferrals, your deferrals are not subject to income tax until distributed from the 

Plan. If you make Roth 401 (k) deferrals, your deferrals are subject to income tax at the time of deferral. 

However, if you satisfy certain distribution requiements, your Roth 401 (k) deferrals and earnings on the deferrals 

will not be subject to income tax when distributed from the Plan. Both types of deferrals are subject to Social 

Security taxes at the time of deferral. Your employer will deduct Social SeCLiity taxes, and in the case of Roth 

deferrals will deduct income taxes, from your remaining pay. 

You may defer up to $10.75 per hour (not to exceed 100% of your pay) each Plan Year, but not more than the 

annual deferral limit in effect each calendar year (this limit is $17,500 for 2014, and as indexed by the IRS for 

inflation thereafter). Participants who will be age 50 or older during 2014 can contribute additional "catcll-up" 

contributions up to $5,500 for 2014 (or up to $14.00 per hour). 

For purposes of your deferral election, "pay" (available for deferrals) is generally defined as your compensation 

reported on Form W-2, and any amounts deferred under this Plan, as well as under any cafeteria plan sponsored 

by your employer. However, under the federal tax laws, pay in excess of $260,000 (for 2014) may not be taken 

into account for Plan purposes. Please refer to the SPD for additional information regarding the type and amount 

of pay that may be deferred. 

See the "FOR ADDITIONAL INFORMATION," section of this notice, to find out how to get a copy of the current 

SPD and other information about the Plan. 

How to Make Cash or Deferred Elections 

To defer a portion of your pay, you must complete and submit the appropriate form. The Northern California 

Carpenters 401(k) Plan Enrollment/Contribution Change Form is available from the Fund Office, found by 

accessing our website at www.carpentertunds.com, or by scanning the QR barcode located at the end of this 

notice. Once enrolled, you must also contact New York Life to make investment elections for future contributions. 

Periods Available for Making Cash or Deferred Elections 

In accordance with Plan rules, you may change your deferral contribution election (pre-tax and/or Roth) at any 

time by completing and submitting the proper form to your employer. The Northern California Carpenters 

401(k) Plan Enrollment/Contribution Change Formis available at the Fund Office, or found by accessing our 

website at www.carpenterfunds.com, or found by scanning the QR barcode located at the end of this notice. The 

change in contribution amount will be effective as soon as administratively possible (but no later than one month 

following the election to change). Participants can stop contributing by completing a Contribution Change Form. 

Contributions should stop as soon as administratively possible. (PLEASE NOTE: Even though the Plan rules 

allow an election change at any time, for administrative purposes your Employer may limit changes to once in a 

30 day period.} 

Applicable Vesting Provisions 

You are always 100% vested in your deferral contributions (pre-tax and/or Roth}, any rollover contributions you 

may have made, and any employer "safe-harbor'' non-elective contributions made on your behalf (adjusted for 

investment gains and losses}. 

Applicable Withdrawal Provisions 

You generally may not withdraw your deferral contributions (pre-tax and/or Roth) or any safe-harbor non-elective 

contributions except when one of the following events occurs: severance from employment with your employer, 

death, disability, or attainment of age 59Yz. You may, however, obtain a "hardship withdrawal" that includes your 

deferral contributions if you satisfy certain IRS requirements.


You may also withdraw any rollover contributions you may have made (adjusted for investment gains and losses) 

at any time. You may withdraw all or any portion of your vested account once you have attained age 59Yz. The 

minimum amount you can withdraw is $500. 

If you are a collectively bargained employee, you may request a distribution of your entire vested account if you 

have ceased working in "covered employmene (i.e., employment with an employer that allows participa1on in this 

Plan) for at least six (6) months. If you are not a collectively bargained employee, you may request a distribution 

of your entire vested account immediately following yourtermination of employment. In either case, you may also 

elect to defer payment until a later date, as permitted by law. 

All withdrawals are subject to rules and procedures as may be established by the Plan Administrator. These are 

described in more detail in the Plan's SPD. 

See the section below "FOR ADDITIONAL INFORMATION" to find out how to get a copy of the current SPD and 

other information about the Plan. 

Plan Amendment and Tennination 

The Trustees retain the right to amend the Plan, including the right to terminate the Plan and discontinue all 

contributions (including the safe harbor non-elective contribution) under the Plan. Termination of the Plan will not 

affect your right to receive any contributions you have accrued adjusted for investment gains and losses as of the 

effective date of the termination. 

FOR ADDITIONAL INFORMATION 

You should consult the Plan document and SPD for a complete explanation of the Plan's features and information 

regarding your rights under the Plan. You may access the SPD on-line at www.carpenterfunds.com or by 

contacting New York Life. You may access your account information via the Internet 

(www.mylife.newyorklife.com) or by phone at (800) 294-3575. 

You can also obtain additional information about the Plan through New York Life or by contacting the Board of 

Trustees, Northern California Carpenters 401 (k) Plan (the "Trustees"). The Trustees also serve as the Plan 

Administrator and may be contacted at: 

Board of Trustees, Northern California Carpenters 401 (k) Plan 

265 Hegenberger Road, Suite 100 - Oakland, CA 94621-0180 

Phone: (510) 633-0333; (888) 547-2054 


EIN: 80-0204601 

This Notice is not intended, nor should you construe it, to modify any aspect of the current Plan document or 

Summary Plan Description. 

Forms and information can be found by accessing our website at www.carpenterfunds.com 

Scan the QR barcode below for a direct link to a 

Northern California Carpenters 401(k) Plan Enrollment/Contribution Change Form 

Note: In order to scan QR codes, your mobile device must have a QR code reader installed. 

You may be able to find a QR code application aRline or bundled with your phone.




265 Hegenberger Road, Suite 100 ~ P .0. Box 2280 


Tel. (510) 633-0333 ~ (888) 547-2054 ~ Fax (510) 633-0215 


August 14, 2014 

To: 

From: 

Re: 

All Active Participants 


);> Plan A & Plan R 

Carpenters Annuity Trust Fund for Northam California 

Carpenters Vacation and Holiday Trust Fund for Northern California 

Northern California Carpenters 401(k) Trust Fund 

Boards of Trustees 

IMPORTANT PLAN INFORMATION- ANNUAL NOTICES 

The enclosed notices provide important infonnation regarding your various Carpenter Plans. Please review this 

infonnation carefully, and keep it where you can find it with your other Plan documents. 

. . · 

· NoricE.s AND oiscRIPTtONs 

' . " 

.. 

. . 

.· ·Palil{$) . 

ELECTRONIC DELIVERY OF PLAN MATERIALS (E-delivery) 

./ Have you considered receiving Plan materials and communications from the Fund Office electronically? 

Electronic delivery of Plan documents Is convenient, simplifies your recordkeeping, reduces paper 

clutter; ensuf9s fast delivery, and allows more of your contributions to be spent on benefits by saving on 

printing and postage costs. ENROLL TODAY and join the incf9asing number of those participating in 

E-delivery. To get started complete and retum the enrollment form provided on the following 

page. 

SUMMARY OF BENEFITS AND COVERAGE (Plan A & Plan R) 

-/ As required by law, group health plans like ours are providing plan participants with a Summary of 

Benefits and Coverage (SBC) as a way to help understand and compare medical benefits. The SBC 

provides a brief overview of the medical plan benefits provided by the Carpenters Health and Welfare 

Trost Fund for CBiifomia. Please share this SBC with your family members who are also covered by the 

Plan. 

NOTICE OF CREDITABLE COVERAGE (Applicable to those eligible for Medicare) 

./ A notice for palticipants with Medicare stating that your group carpenters Health & Welfaf9 Plan's 

pT9scriptlon drug coverage Is, on averege, at least as good as standard prescription drug coverage 

under Medicare Part D. 

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) 

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION (PHI) 

./ Notice to participants describing their rights for obtaining a copy of the Plan's legal duties with T9Spect 

to PHI and Plan uses and disclosures of PHI. 

WOMEN'S HEALTH AND CANCER RIGHTS ACT (WHCRA) NOTICE 

-/ A description of benefits under the WHCRA and any deductibles, co-payments, coinsurance, and lim;ts 

applicable to such benefits. 

SPECIAL EXTENSION OF COVERAGE FOR CERTAIN DEPENDENT STUDENTS ON A MEDICALLY 

NECESSARY LEAVE OF ABSENCE 

./ A notice explaining that extended coverage is available for post-secondary education students on 

medical leave. 

Group 1/Actlve/A&R


DISCLOSURE OF "GRANDFATHER" STATUS 

./ A grandfathered plan must include a statement to that effect in any materials describing benefits 

provided under a plan to alert participants and beneficiaries that certain consumer protections may not 

apply. 

MEDICAID AND THE CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) NOTICE 

OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND FAMILIES 

./ A group health plan in a state that provides premium assistance under Medicaid or Children's Health 

Insurance Program (CHIP) must notify all employees of potential opportunities for premium assistance 

in the state in which employee resides. 

SUMMARY ANNUAL REPORTS 

./ The enclosed reports are summaries of the annual reports filed for the Carpenters Health and Welfare 

Trust Fund for California, the Carpenters Annuity Trust Fund for Northern California, the Northern 

California Carpenters 401(k) Trust Fund, and the Carpenters Vacation and Holiday Trust Fund for 

Northern California. 

FEE DISCLOSURE NOTICE 

./ This document includes important information to help you carefully compare the investment options 

available under your retirement Plan(s). To comply with federal regulations this Information, which 

contains retirement plan fee information, is being distributed for participant directed individual account 

plans. If you have not elected to self-direct investments in your Annuity Account, or have not enrolled in 

the Northam California Carpenters 401 (k) Plan, these Investment options and fees do not apply. 

For more information about these notices, or the Plans in general, please contact the Trust Fund Office at: 


P.O. Box 2280 


Toll-Free: (888) 547-2054 or (510) 633-0333 

benefrtservices@carpenterfunds.com 

carpenterfunds.com 

The Board af Trustees of each of the Carpenter Plans maintains the right ta change or discontinue the types and 

amounts of benefits under each Plan. This notice is intended as a summary only, and actual Plan documents will be 

used to interpret each Plan. Only the full Board of Trustees of each Plan is authorized to interpret the Plan and has 

discretion to decide all questions about the Plan, including questions about your eligibility for benefits and the 

amount of any benefits payable to you. No individual Trustee, Employer or Union Representative has authority to 

interpret any of the Carpenters Plans on behalf of the Board(s) or to act as an agent of the Board(s). 

AVISO 

Si usted tiene dificultad en entender alguna parte de este folleto, comunrquese con Carpenter Funds 

Administrative Office en 265 Hegenberger Road, Suite 100, Oakland, CA 94621. Las horas de oficina son de 

8:00a.m. a 5:00 p.m., Junes a viernes. Usted tambien puede llamar a Ia oficina del Plan, telefono 888-547- 

2054, para ayuda. 

Group 1/Active/A&R


August 14, 2014 

CARPENTERS HEALTH AND WELFARE TRUST FUND FOR CALIFORNIA 

265 Hegenberger Road, Suite 100 

P.O. Box 2280 


Tel. (510) 633-0333 ~ (888) 547-2054 ~Fax (510) 633-0215 

www.carnenterfunds.com 

To: 

All Active Participants and their Beneficiaries - Plan A and Plan R 

From: BOARD OF TRUSTEES 


Re: 

SUMMARY OF BENEFITS AND COVERAGE (SBC) required by the Affordable Care Act (ACA) 

As required by law, group health plans like ours are providing plan participants with a Summary of Benefits and 

Coverage (SBC) as a way to help understand and compare medical benefits. The SBC provides a brief overview of 

the medical plan benefits provided by the Carpenters Health and Welfare Trust Fund for California. Please share 

this SBC with your family members who are also covered by the Plan. 

Each SBC contains concise medical plan information in plain language about benefits and coverage. This includes 

what is covered, what you need to pay for various benefits, what is not covered, and where to go for more 

information or to get answers to questions. Government regulations are very specific about the information that can 

and cannot be included in each SBC. The Plan is not allowed to customize much of the SBC. An SBC includes: 

• A health plan comparison tool called "Coverage Examples: These examples illustrate how the medical 

plan covers care for two common health scenarios: having a baby and diabetes care. These examples 

show the projected total costs associated with each of these two situations, how much of these costs the 

Plan covers and how much you, the participant, need to pay. In these examples, it's important to note that 

the costs are national averages and do not reflect what the actual services might cost in your area. Plus, 

the cost for your treatment might also be very different depending on your doctor's approach, whether your 

doctor is an In-Network PPO Provider or a Non-PPO Provider, your age and any other health issues you 

may also have. These examples are there to help you compare how different health plans might cover the 

same condition-not for predicting your own actual costs. 

• A link to a "Glossary~ of common terms used in describing health benefits, including words such as 

"deductible," •co-payment," and "co-insurance." The glossary is standard and cannot be customized by a 

Plan. 

• Websites and toll-free phone numbers you can contact if you have questions or need assistance with 

benefits. 

Please keep this notice with your benefit booklet. If you have any questions, please call Benefit Services at the 

Trust Fund Office at (510) 633-0333 or toll free at (888) 547-2054. You may also send an email to 

benefitservices@carcenterfunds.com. 

Group 1/Actlve/A&R 

Page 3




265 Hegenberger Road, Suite 100 -¢-P.O. Box 2280 


Tel. (510} 633-0333-¢- {888) 547-2054-¢- Fax (510) 633-0215 


August 14, 2014 

To: 

From: 

Re: 

All Active Participants of the Carpenters Health and Welfare Trust Fund for California 


Notice of Creditable Coverage 

Important Information about Medicare Prescription Drug Program (Part D) 

If you and your eligible dependents are not eligible for Medicare and will not be eligible during 

the next year you may disregard this Notice. If, however, you and/or any family members are now 

eligible for Medicare or will become eligible for Medicare in the next year, you should read this Notice. 

Attached is your "Notice of Creditable Coverage," which all Trust Funds that provide prescription . drug 

coverage for individuals who are Medicare eligible are required by law to provide annually. Because it is not 

possible for our Plan t() always know when a participant or his/her dependents has or will soon become 

eligible for Medicare, we are sending the Notice to all Active Plan Participants. 

Your current prescription drug coverage provided through the Carpenters Health and Welfare Trust Fund 

provides prescription drug coverage that is at least as good as the standard Medicare prescription drug 

program. This means that your current prescription coverage is creditable and you do NOT need to 

enroll In Part D of Medicare. 

If you would like to discuss your options for prescription drugs, call the Fund Office at (51 0) 633-0333 or toll 

free at (888) 547-2054. 

Groupl/ AclivcA&R/ 

Page 23


August 14, 2014 



265 Hegenberger Road, Suite 100 ~P.O. Box 2280 


Tel. (510) 633-0333 ~ (888) 547-2054 ~Fax (510) 633-0215 


To: 

From: 

Re: 

All Active Participants of the Carpenters Health and Welfare Trust Fund for California 


Notice of Creditable Coverage 

Important lnfonnatlon about Medicare Prescription Drug Program (Part D) 

This notice is for people with Medicare or may become eligible for Medicare. 

Please read this noti~e carefully and keep it where you can find it. 

This Notice has infonnation about your current prescription drug coverage with Carpenters Health and 

Welfare Trust Fund for California and the prescription drug coverage available for people with Medicare. It 

also explains the options you have under Medicare's prescription drug coverage and can help you decide 

whether or not you want to enroll in that Medicare prescription drug coverage. At the end of this notice is 

information on where you can get help to make a decision about Medicare's prescription drug coverage. 

> If you and/or your family members are not now eligible for Medicare, and 

will not be eligible during the . next 12 months, you may disregard this 

Notice. 

> If, however, you and/or your family members are now eligible for Medicare 

or may become eligible for Medicare in the next 12 months, you should read 

this Notice very carefully. 

Prescription drug coverage for Medicare-eligible people Is available through Medicare prescription drug 

plans (POPs) and Medicare Advantage Plans (like an HMO or PPO) that offer prescription drug coverage. 

All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some 

plans may also offer more drug coverage for a higher monthly premium. 

The Trust Fund has detennined that the prescription drug coverage under the 

Carpenters Health and Welfare Trust Fund for California - Indemnity Medical Plan Cas 

administered by Express Scripts) is "creditable." (Kaiser and Health Net plans are actual 

Medicare Part D plans and this notice does not apply to participants who are covered by 

those plans.) · 

Coverage is "Creditable" if the value of this Plan's prescription drug benefit equals or exceeds 

the value of the standard Medicare prescription drug coverage. In other words, the benefit is, 

on average for all plan participants, expected to pay out as much or more than the standard 

Medicare prescription drug coverage will pay. 

Because the Plan option(s) noted above are, on average, at least as good as the standard Medicare 

prescription drug coverage, you can keep your prescription drug coverage under Carpenters Health 

and Welfare Trust Fund for California, and you do not need to enroll in a Medicare prescription drug 

program. You will not pay extra if you later decide to enroll in Medicare prescription drug coverage. 

You may enroll in Medicare prescription drug coverage at a later time, and because you maintain creditable 

coverage, you will not have to pay a higher premium (a late enrollment penalty). 

Groupl/ ActiveA&R/ 

Page 25


REMEMBER TO KEEP THIS NOTICE 

If you decide to join one of the Medicare drug plans, you may be required to provide a 

copy of this notice when you join to show whether or not you have maintained 

creditable coverage and,. therefore, whether or not you are required to pay a higher 

premium (a penalty). 

WHEN CAN YOU JOIN A MEDICARE DRUG PLAN? 

Medicare-eligible people can enroll in a Medicare prescription drug plan at one of the following three (3) 

times: 

• when they first become eligible for Medicare; or 

• during Medicare's annual election period (from October 15th through December 7th ); or 

• for beneficiaries leaving employer/union coverage, you may be eligible for a Special Enrollment Period 

(SEP) in which to sign up for a Medicare prescription drug plan. 

When you make your decision whether to enroll in a Medicare prescription drug plan, you should also 

compare your current prescription drug coverage, (including which drugs are covered and at what cost) with 

the coverage and cost of the plans offering Medicare prescription drug coverage in your area. 

YOUR RIGHT TO RECEIVE A NOTICE 

You will receive this notice at least every 12 months and at other times in the future such as if the 

creditable/non-creditable status of the prescription drug coverage through this plan changes. You may also 

request a copy of a Notice at any time. 

WHY CREDITABLE COVERAGE IS IMPORTANT (When you will pay a higher premium (penalty) to 

join a Medicare drug plan) 

If you do not have creditable prescription drug coverage when you are first eligible to enroll in a Medicare 

prescription drug plan and you elect or continue prescription drug coverage under a non-creditable 

prescription drug plan, then at a later date when you decide to elect Medicare prescription drug coverage, 

you may pay a higher premium (a penalty) for that Medicare prescription drug coverage for as long as you 

have that Medicare coverage. 

Maintaining creditable prescription drug coverage will help you avoid Medicare's late enrollment penalty. 

This late enrollment penalty is described below: 

If you go 63 continuous days or longer without creditable prescription drug coverage (meaning drug 

coverage that is at least as good as Medicare's prescription drug coverage), your monthly premium 

may go up by at least 1% of the Medicare base beneficiary premium per month for every month that 

you did not have either Medicare prescription drug coverage or coverage under a creditable 

prescription drug plan. You may have to pay this higher premium (the penalty) as long as you have 

Medicare prescription drug coverage. 

For example, if 19 months pass where you do not have creditable prescription drug coverage, when 

you decide to join Medicare's drug coverage your monthly premium will always be at least 19% 

higher than the Medicare base beneficiary premium. Additionally, if you go 63 continuous days or 

longer without creditable prescription drug coverage you may also have to wait until the next 

October to enroll for Medicare prescription drug coverage. 


Page 26


WHAT ARE YOUR CHOICES? 

You can choose either one of the following options: 

OPTION 1 

What you can do: 

You can select or keep your current prescription drug coverage with Carpenters Health and Welfare Trust Fund for 

California, and you do not have to enroll in a Medicare prescription drug plan. · 

What this option means to you: 

You will continue to be able to use your prescription drug beneflt,s through Carpenters Health and Welfare Trust Fund 

for California. 

• You may, in the future, enroll in a Medicare prescription drug plan during Medicare's annual enrollment period 

(during October 15 through December 7 of each year). 

• As long as you are enrolled in creditable drug coverage you will not have to pay a higher premium (a late 

enrollment fee) to Medicare when you do choose, at a later date, to sign up for a Medicare prescription drug 

plan. 

OPTION 2 

What you can do: 

This option applies to Indemnity Medical Plan members only. You can select or keep your current Indemnity 

medical and prescription drug coverage with Carpenters Health and Welfare Trust Fund for California and also enroll 

in a Medicare prescription drug plan. 

You will need to pay the Medicare Part D premium out of your own pocket. 

What this option means to you: 

Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare 

prescription drug plan, and you are in the Indemnity Medical Plan, you and your eligible dependents will still be eligible 

to receive all of your current health and prescription drug benefits. 

For Indemnity Medical Plan Members Only: Having dual prescription drug coverage under the Active Plan and 

Medicare means that you will still be able to receive all your current health coverage and this Plan will coordinate its 

drug payments with Medicare. This group health plan pays primary and Medicare Part D coverage pays secondary. 

Note that you may not drop just the prescription drug coverage under Carpenters Health and Welfare Trust Fund for 

California. That is because prescription drug coverage is part of the entire medical Plan. 

Note that each Medicare prescription drug plan (PDP) may differ. Compare coverage, such as: 

• POPs may have different premium amounts; 

• POPs may cover different brand name drugs at different costs to you; 

• POPs may have different prescription drug deductibles and different drug copayments; 

• POPs may have different networks for retail pharmacies and mail order services. 

Groupl/ ActivcA&R/ 

Page 27


FOR MORE INFORMATION ABOUT YOUR OPTIONS UNDER MEDICARE'S PRESCRIPTION DRUG 

COVERAGE 

More detailed information about Medicare plans that offer prescription drug coverage is available in the 

"Medicare & You" handbook. A person enrolled in Medicare (a "beneficiary'') will get a copy of this 

handbook in the mail each year from Medicare. A Medicare beneficiary may also be contacted directly by 

Medicare-approved prescription drug plans. 

For more information about Medicare prescription drug coverage: 

• Visit www.medicare.gov 

• Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook 

for their telephone number), for personalized help 

• Caii1-800-MEDICARE (1-800-633-4227). TTY users should call1-877-486-2048. 

Para mas informacion sobre sus opciones bajo Ia cobertura de Medicare para recetas medicas. 

Revise el manual "Medicare Y Usted" para informaci6n detallada sobre los planes de Medicare que ofrecen 

cobertura para recetas medicas. Visite www.medicare.gov per el Internet o llame GRATIS al 1 800 

MEDICARE (1-800-633-4227). Los usuaries con telefono de texto (TTY) deben de llamar al 1-877-486- 

2048. Para mas informaci6n sobre Ia ayuda adicional, visite Ia SSA en linea en www.socialsecurity.gov por 

Internet, o llameles al 1-800-772-1213 (Los usuaries con telefono de texto (TTY) deben de llamar al 1-800- 

325-0778). 

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is 

available. Information about this extra help is available from the Social Security Administration (SSA). For 

more information about this extra help, ·visit SSA online at www.socialsecurity.gov, or call them at 1-800- 

772-1213 (TTY 1-800-325-0778). 

For more information about this notice or your current prescription drug coverage contact: 

Contact: Benefit Services Department 

Address: 265 Hegenberger Road, Suite 100, Oakland, CA 94621 

Phone Number: (888) 547-2054 

As in all cases, the Carpenters Health and Welfare Trust Fund for California reserves the right to modify 

benefits at any time, in accordance with applicable law. This document dated August 14, 2014 is intended 

to serve as your Medicare Notice of Creditable Coverage, as required by law. 

Groupl/ Ac:tivcA&R/ 

Page 28




265 Hegenberger Road, Suite 100 ~P.O. Box 2280 


Tel. (510) 633-0333 ~ (888) 547-2054 ~Fax (510) 633-0215 


HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAAl 

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION


SPECIAL EXTENSION OF COVERAGE FOR CERTAIN DEPENDENT STUDENTS ON A MEDICALLY 

NECESSARY LEAVE OF ABSENCE 

If you have a dependent child that is over the age of 18 and is enrolled in a post-secondary institution (i.e. 

college or university) and the Plan receives a written certification from a covered child's treating physician 

that: 

(1) the child is suffering from a serious illness or injury, and 

(2) a leave of absence (or other change in enrollment) from a post-secondary institution is medically 

necessary, and the loss of postsecondary stude.nt status would result in a loss of health coverage 

under the Plan, then the Plan will extend the child's coverage for up to one year. 

This maximum one-year extension of coverage begins on the first day of the medically necessary leave of 

absence {or other change in enrollment) and ends on the date that is the earlier of (1) one year later, or (2) 

the date on which coverage would otherwise terminate under the terms of the Plan. Contact the Trust Fund· 

Office for more information. 

DISCLOSURE OF "GRANDFATHER" STATUS 

This group health Plan believes that the Indemnity and HMO plans are considered to be "grandfathered 

health plans" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted 

by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage already 

in effect when that law was enacted. 

Being a grandfathered health plan means that certain consumer protections of the Affordable Care Act that 

apply to other plans may not be required. For example, the requirement for the provision of preventive 

health services without any cost sharing. However, grandfathered health plans must comply with certain 

other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on 

benefits. 

Questions regarding which protections apply and which protections do not apply to a grandfathered health 

plan and what might cause a plan to change from grandfathered health plan status can be directed to the 

Trust Fund Office at {510) 633-0333 or Toll Free at (888) 547-2054. You may also contact the Employee 

Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or 

http://www.dol.gov/ebsa/healthreform/. This website has a table summarizing which protections do and do 

not apply to grandfathered health plans. 

MEDICAID AND THE CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) NOTICE 

OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND FAMILIES 

If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your 

employer, your State may have a premium assistance program that can help pay for coverage, using funds 

from their Medicaid or CHIP programs. If you or your children aren't eligible for Medicaid or CHIP, you will 

not be eligible for these premium assistance programs but you may be able to buy individual insurance 

coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. 

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, 

contact your State Medicaid or CHIP office to find out if premium assistance is available. 


Page 30


If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your 

dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 

1-877-KIDS NOW or www.lnsurekidsnow.gov to find out how to apply. If you qualify, ask your State if it 

has a program that might help you pay the premiums for an employer-sponsored plan. 

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible 

under your employer plan, your employer must allow you to enroll in your employer plan if you are not 

already enrolled. This is called a "special enrollment" opportunity, and you must request coverage within 

60 days of being determined eligible for premium assistance. If you have questions about enrolling in 

your employer plan, you can contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444- 

EBSA {3272). 

If you live in one of the following States, you may be eligible for assistance paying your employer 

health plan premiums. The following list of States is current as of January 31, 2014. Contact your 

State for further mnfonnation on eligibility - 

ALABAMA- Medicaid 

COLORADO - Medicaid 

Website: http:/lwwiN.medicaid.alabama.gov 

Medicaid Website: http://www.colorado.gov/ 

Phone: 1-855-692-5447 Medicaid Phone (In state): 1-800-866-3513 

Medicaid Phone (Out of state}: 1-80D-221-3943 

ALASKA- Medicaid 

Website: 

http://health.hss.state.ak.us/dpa/programs/medicaid/ 

Phone (Outside of Anchorage): 1-888-318-8890 

Phone (Anchorage): 907-269-6529 

ARIZONA- CHIP 

FLORIDA- Medicaid 

Website: https:/lwww.flmedicaidtplrecovery.com/ 

Website: http:/lwwiN.azahcccs.gov/applicants 

Phone (Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268 

Phone (Maricopa County}: 602-417-5437 

GEORGIA- Medicaid 

Website: http://dch.georgla.gov/ 

Click on Programs, then Medicaid, then Health 

Insurance Premium Payment (HIPP) 

Phone: 1-SOD-869-1150 

IDAHO- Medicaid 

MONTANA ..... Medicaid 

Medicaid Website: 

Website: 

http://healthandwelfare.idaho.gov/Medicai/Medicaid/Pre http://medicaidprovider. hhs. mt.gov/clientpages/ 

miumAssistance/tabid/151 0/Default. aspx 

clientindex.shtml 

Medicaid Phone: 1-800-926-2588 Phone: 1-800-694-3084 

INDIANA- Medicaid 

NEBRASKA- Medicaid 

Website: http://www.in.gov/fssa 

Website: www.ACCESSNebraska.ne.gov 

Phone: 1-800-889-9949 Phone: 1-800-383-4278 

Gmupl/ AdiveA&R./ 

Page 31


IOWA- Medicaid 

NEVADA- Medicaid 

Website: www.dhs.state.ia.us/hipp/ 

Medicaid Website: http://dwss:nv.gov/ 

Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900 

KANSAS- Medicaid 

Website: http://www.kdheks.gov/hcf/ 

Phone: 1-800-792-4884 

KENTUCKY- Medicaid 

NEW HAMPSHIRE - Medicaid 

Website: http://chfs. ky.gov/dms/default. htm 

Website: 

Phone: 1-800-635-2570 

http://www.dhhs.nh.gov/oii/documentslhippapp.pdf 

Phone: 603-271-5218 

LOUISIANA- Medicaid 

NEW JERSEY- Medicaid and CHIP 

Website: http://www.lahipp.dhh.louisiana.gov 

Medicaid Website: ttp://www.state. nj. us/humanservices/ 

Phone: 1-888-695-2447 

dmahs/clients/medicaid/ 

Medicaid Phone: 609-631-2392 

MAINE- Medicaid 

CHIP Website: http://www.njfamilycare.org/index.html 

Website: CHIP Phone: 1-800-701-0710 

http://www.malne.gov/dhhs/ofilpublic-assistancelindex.html 

Phone: 1-800-977-6740 

TIY 1-800-977-6741 

MASSACHUSETTS- Medicaid and CHIP NEW YORK- Medicaid 

Website: http://www.mass.gov/MassHealth 

Website: http://www.nyhealth.gov/health_care/medicaid/ 

Phone: 1-800-462-1120 Phone: 1-800-541-2831 

MINNESOTA- Medicaid 

Website: http://www.dhs.state.mn.us/ 

Click on Health Care, then Medical Assistance 

Phone: 1-800-657-3629 

NORTH CAROLINA- Medicaid 

Website: http://www.ncdhhs.gov/dma 

Phone:919-855-4100 

MISSOURI - Medicaid 

NORTH DAKOTA- Medicaid 

Website: 

Website: 

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm http://www.nd.gov/dhs/services/medicalserv/medicaid/ 

Phone: 573-751-2005 Phone: 1-800-755-2604 

OKLAHOMA- Medicaid and CHIP 

UTAH- Medicaid and CHIP 

Website: http://www.insureoklahoma.org 

Website: http://health.utah.gov/upp 

Phone: 1-888-365-3742 Phone: 1-866-435-7414 

OREGON - Medicaid 

VERMONT- Medicaid 

Website: http://www.oregonhealthykids.gov 

Website: http://www.greenmountaincare.org/ 

http://www. hijossaludablesoregon.gov Phone: 1-800-250-8427 

Phone: 1-800-699-9075 

PENNSYLVANIA- Medicaid 

Website: http://www.dpw.state.pa.us/hipp 

Phone: 1-800-692-7462 

VIRGINIA- Medicaid and CHIP 

Medicaid Website: http://www.dmas. virginia.gov/rcp- 

HIPP.htm 

Medicaid Phone: 1-800-432-5924 

CHIP Website: http://www.famis.org/ 

CHIP Phone: 1-866-873-2647 


Page 32


1 

RHODE ISLAND- Medicaid 

Website: www.ohhs.ri.gov 

Phone: 401-462-5300 

SOUTH CAROLINA- Medicaid 

Website: http://www.scdhhs.gov 

Phone: 1-888-549-0820 

SOUTH DAKOTA - Medicaid 

WISCONSIN - Medicaid 

Website: http://dss.sd.gov 

Phone: 1-888-828-0059 Phone: 1-800-362-3002 

WASHINGTON - Medicaid 

Website: 

http://www.hca.wa.gov/medicaid/premiumpymt/pages/in 

I 

dex.aspx 

Phone: 1-800-562-3022 ext. 15473 

WEST VIRGINIA- Medicaid 

Website: www.dhhr.wv.gov/bms/ 

Phone: 1-877-598-5820, HMS Third Party Liability 

Website: http://www.badgercarepius.org/pubs/p-10095.htm 

TEXAS - Medicaid 

WYOMING- Medicaid 

Website: https:/lwww.gethipptexas.com/ 

Website: http://health.wyo.gov/healthcarefin/equalitycare 

Phone: 1-800-440-0493 Phone: 307-777-7531 

To see if any other States have added a premium assistance program since January 31 , 2014, or for more 

information on special enrollment rights, contact either: 

U.S. Department of Labor 

Employee Benefits Security Administration 

www.dol.gov/ebsa 

1-866-444-EBSA {3272) 

U.S. Department of Health and Human Services 

Centers for Medicare & Medicaid Services 

www.cms.hhs.gov 

1-877-267-2323, Menu Option 4, Ext. 61565 

Group1/ ActiveA&R/ 

Page 33


SUMMARY ANNUAL REPORT FOR 

CARPENTERS HEALTH AND WELFARE TRUST FUND FOR CALIFORNIA 

Plan Year- September 1, 2012 through August 31, 2013 

This is a summary of the annual report for the Carpenters Health and Welfare Trust Fund for California, Employer 

Identification Number 94-1234856, a Health and Welfare Plan, for the period September 1, 2012 through August 31, 

2013. The annual report has been filed with the Employee Benefits Security Administration, as required under the 

Employee Retirement Income Security Act of 1974 (ERISA). 

The Board of Trustees of the Carpenters Health and Welfare Trust Fund for California has committed the Fund to pay 

Medical, Hospital, Dental, Orthodontia, Prescription Drug, Vision, Hearing Aid, Physical Examination, and Weekly 

Disability claims under the terms of the Plan. 

Insurance Information: 

The Plan has contracts with Kaiser Foundation Health Plan, Inc., and Health Net to provide medical and hospital 

coverage, OptumHealth Behavioral Solutions of California to provide a member assistance program and mental health 

and chemical dependency benefits, lNG Employee Benefits to provide accidental death, dismemberment, and life 

insurance benefits, and AIG Benefits Solutions to provide stop Joss coverage. The total premiums paid for all contracts 

for the Plan year ending August 31, 2013 were $166,335,594. 

Basic Financial Statement: 

The value of Plan assets, after subtracting liabilities of the Plan, was $373,822,798 minus premiums and self-funded 

claims payable of $49,794,235, minus claims incl,!rred but not reported of $10,391,000, minus bank of hours liability of 

$107,740,000, equals $205,897,563 as of August 31, 2013, compared to $340,479,989 minus premiums and selffunded 

claims payable of $40,310,292, minus claims incurred but not reported of $15,572,000, minus bank of hours 

liability of $98,983,000, equals $185,614,697 as of September 1, 2012. During the Plan year, the Plan experienced an 

increase in its net assets of $20,282,866. This increase included unrealized appreciation or depreciation in the value 

of Plan assets; that is, the difference between the value of the Plan's assets at the end of the year and the value of the 

assets at the beginning of the year, or the cost of assets acquired during the year. 

Condensed Financial statement 

Beginning Balance As of 09/01/2011 Aa of &910112012 · 

Value of Net Plan Assets $194,809,540 $186,614,691 

Employer Contributions $237,846,090 $265,550,141 

Participant Contributions $24,506,289 . $23,164,047 

Investments - Earnings $13,457,575 $18,426.421 

Sale of Assets - Earnings/Losses -$435,003 $4,561,419 

Other Income $6,555,920 $10,090,888· 

Plan Income $281,930,871 $321,782,916 

Insurance Premiums $142,147,173 $166,335,594 

Self-Funded Benefits $135,585,959 $121,741,453 

Administrative Fees $12,712,390 $12,573,299 

Investment Expenses $680,192 $849,704 

Total Expenses $291,125,714 $301,100,050 

Ending Balance As of 08/31/2012 As of0813112013 


Group1/A&R 

Page 34


The Plan had total incrime of $321,782,916; including employer contributions of $265,550,141, participant 

contributions of $23,164,047, a gain of $4,551,419 from the sale of assets, earnings from Investments of $18,426,421, 

and other income of $10,090,888. 

Plan expenses were $301,500,050. These expenses included $12,573,299 in administrative expenses, $849,704 in 

investment expenses, $166,335,594 in premium costs, $121,741,453 in self-funded benefits paid directly to 

participants and beneficiaries or to service providers on their behalf. 

Your Rights to Additional Information: 

You have the right to receive a copy of the full annual report, or any part thereof, on request. The following items are 

included in that report: 1) An accountant's report, 2) Insurance information including sales commission paid by 

insurance carriers, 3) Assets held for investments; and 4) Transactions in excess of five percent of Plan assets. 

Obtaining Copies of a Summary Annual Report 

The report provided is a summary of the annual report filed for the Carpenters Health and Welfare Trust Fund for 

California. To obtain a copy of the full annual report or any part thereof, write or call the Carpenter Funds 

Administrative Office of Northern California, Inc., which is the Fund Manager appointed by the Plans' Administrator, 

265 Hegenberger Road, Suite 100, Oakland, California 94621; telephone (888) 547-2054. The charge to cover 

copying costs will be $15.00 per full annual report, or $.25 per page for any part thereof. 

You also have the right to receive from the Plan Administrator, on request and at no charge, a statement of the assets 

and liabilities of the Plan and accompanying notes, or a statement of Income and expenses of the Plan and 

accompanying notes, or both. If you request a copy of a full annual report from the Plan Administrator, these two 

statements and accompanying notes will be included as part of that report. The charge to cover copying costs given 

above does not include a charge for the copying of these portions of the report because these portions are furnished 

without charge. 

You also have the legally protected right to examine the annual report at the main office of the Plan, 265 Hegenberger 

Road, Suite 100, Oakland, California 94621 and at the U.S. Department of Labor in Washington, D.C., or to obtain a 

copy from the U.S. Department of Labor (upon payment of copying costs). Requests to the Department of Labor 

should be addressed to: Public Disclosure Room, N-1513, Employee Benefits Security Administration, U.S. 

Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. 

AVISO 

Si usted tiene dificultad en entender alguna parte de este folleto, comunlquese con Carpenter Funds 


8:00a.m. a 5:00p.m., lunes a viernes. Usted tambiem puede !lamar a Ia oficina del Plan, telefono 888-547- 


Group1/A&R 

Page 35



CARPENTERS ANNUITY TRUST FUND FOR NORTHERN CALIFORNIA 


This is a summary of the annual report for the Carpenters Annuity Trust Fund for Northern California, Employer 

Identification Number 94-6534591, for the period September 1, 2012 through August 31,2013. The annual report has 

been filed with the Employee Benefits Security Administration, as required under the Employee Retirement Income 

Security Act of 1974 (ERISA}. 


Benefits under the Plan are provided by the Carpenters Annuity Trust Fund for Northern California. Plan expenses 

were $97,901,032. These expenses included $2,198,394 in administrative expenses, $4,263,074 in investment 

expenses, and $91,439,564 In benefits paid to participants and beneficiaries. A total of 47,294 persons were 

participants in or beneficiaries of the Plan at the end of the Plan year, although not all of these persons had yet earned 

the right to receive benefits. 

The value of Plan assets, after subtracting liabilities of the Plan, was $1,843,768,168 as of August 31, 2013, compared 

to $1,734,011,842 as of September 1, 2012. During the Pian year, the Plan experienced an increase in its net assets 

of $109,756,326. This increase includes unrealized appreciation or depreciation in the value of Plan assets; that is, the 

difference between the value of the Plan's assets at the end of the year and the value of the assets at the beginning of 

the year, or the cost of assets acquired during the year. 

The Plan had total income of $207,657,358; including employer contributions of $63,470,372, gains of $34,011,273 

from the sale of assets, earnings from investments of $110,045,639, and other income of $130,074. 

Minimum Funding Standards: 


Beginning Balance As of 09/01/2011 Aft of 09101/2012 

Value of Net Plan Assets $1,650,373,714 $1,734,011,842 

Employer Contributions $57,842,146 . $63,470,372 

Investments - Earnings $137,062,613 $110,045,639 

Sale of Assets - Earnings/Losses -$6,481,899 $34,011,273 

Other Income $334,589 $130.074 


Benefits Paid $99,193,377 $91 ,439,564 


Investment Expenses $3,187,639 $4,263,074 


Ending Balance As of 08131/2012 As of 08/31n013 

Value of Net Plan Assets $1,734,011,842 $1,843,768,168 

The Plan received $63,470,372 in employer contributions during the year ended August 31, 2013. The minimum 

funding standards of ERISA have been met. 

Group 1/Active/A&R 

Page 36




included in that report: 1) An accountant's report, 2) Assets held for investment, 3) Transactions in excess of five 

percent of Plan assets, 4) Insurance Information including sa!es commissions paid by insurance carriers; and 5) 

Information regarding any common or collective trust, pooled separate accounts, master trusts or 103-12 Investment 

entities in which the Plan participates. 


The report provided is a summary of the annual report filed for the Carpenters Annuity Trust Fund for Northern. To 

obtain a copy of the full annual report or any part thereof, write or call the Carpenter Funds Administrative Office of 

Northern California, Inc., which is the Fund Manager appointed by the Plans' Administrator, 265 Hegenberger Road, 

Suite 100, Oakland, California 94621; telephone (888} 547-2054. The charge to cover copying costs will be $15.00 per 

full annual report, or $.25 per page for any part thereof. 


and liabilities of the Plan and accompanying notes, or a statement of income and expenses of the Plan and 






Road, Suite 100, Oakland, California 94621 and at the U.S. Departrnent of Labor in Washington, D.C., or to obtain a 




AVISO 

Si usted tiene dificultad en entender alguna parte de este folleto, comunrquese con Carpenter Funds 


8:00a.m. a 5:00p.m., Junes a viemes. Usted tambi~n puede llamar a Ia oficina del Plan, tel~fono 888-547- 


Group 1/ActNe/A&R 

Page 37



NORTHERN CALIFORNIA CARPENTERS 401(K) TRUST FUND 


This is a summary of the annual report for the Northern California Carpenters 401 (k) Trust Fund, Employer 

Identification Number 80-0204601, for the period September 1, 2012 through August 31, 2013. The annual report has 

been filed with the Employee Benefits Security Administration, as required under the Employee Retirement Income 

Security Act of 1974 (ERISA). 


Benefits under the Plan are provided by the Northern California Carpenters 401(k) Trust Fund. Plan expenses were 

$1,322,454. These expenses included $109,394 in administrative expenses, $91,629 in investment expenses, and 

$1,121,431 in benefits paid to participants and beneficiaries. A total of 929 persons were participants in or 

beneficiaries of the Plan at the end of the Plan year, although not all of these persons had yet earned the right to 

receive benefits. 

The value of Plan assets, after subtracting liabilities of the Plan, was $30,503,044 as of August 31, 2013, compared to 

$25,144,534 as of September 1, 2012. During the Plan year, the Plan experienced an increase in its net assets of 

$5,358,510. This increase included unrealized appreciation or depreciation in the value of Plan assets; that is, the 



The Plan had total income of $6,680,964; including employee contributions of $4,845,122, employer match 

contributions of $258,070, other contributions of $11 ,645, earnings from investments of $1,551,729, and other income 

of $14,398. 


Beginning Balance As of 09/01/2011 As of 09.10112012 . 

Value of Net Plan Assets $19,171,944 . ' $25,144,Q4 

Participating Employee Contributions $4,383,456 . $4,845,122 

Employer Contributions $282,132 $258;070 

Other Contributions $309,690 ·$11,645 

Investments - Earnings $2,184,029 $1,551,729 

Other Income $10,515 $14,398 

Plan Income $7,169,822 . $8,680;964 

Benefits Paid $1,054,093 $1,121,431 

Administrative Fees $77,927 $109,394 



Ending Balance As ofOB/31/2012 As of 08131/2013 

Value of Net Plan Assets $25,144,534 $30,.503,044 

Minimum Funding Standards: 

The Plan received $4,845,122 in employee contributions during the year ended August 31, 2013. 

funding standards of ERISA have been met. 

The minimum 

Group 1/ActNe/A&R 

Page 38




included in that report: 1) An accountant's report, 2) Assets held for investment; and 3) Transactions in excess of five 

percent of Plan assets. 


The report provided is a summary of the annual report filed for the Northern California Carpenters 401(k) Trust Fund. 

To obtain a copy of the full annual report or any part thereof, write or call the Carpenter Funds Administrative Office of 

Northern California, Inc., which is the Fund Manager appointed by the Plans' Administrator, 265 Hegenberger Road, 

Suite 100, Oakland, California 94621; telephone (888) 547-2054. The charge to cover copying costs will be $15.00 per 

full annual report, or $.25 per page for any part thereof. 












AVISO 

Si usted tiene dificultad en entender alguna parte de este folleto, comunfquese con Carpenter Funds 


8:00a.m. a 5:00p.m., Junes a viemes. Usted tambiem puede llamar a Ia oficina del Plan, telefono 888-547- 


Group 1/Attive/A&R 

Page 39



CARPENTERS VACATION AND HOLIDAY TRUST FUND FOR NORTHERN CALIFORNIA 


This is a summary of the annual report for the Carpenters Vacation and Holiday Trust Fund for Northern California, 

Employer Identification Number 94-6276537, a Vacation and Holiday Plan, for the period September 1, 2012 through 

August 31, 2013. The annual report has been filed with the Employee Benefits Security Administration, as required 

under the Employee Retirement Income Security Act of 197 4 (ERISA). 

The Board of Trustees of the Carpenters Vacation and Holiday Trust Fund for Northern California has committed the 

Fund to pay all vacation and holiday benefits incurred under the terms of the Plan; 


The value of Plan assets, after subtracting liabilities of the Plan, was $6,917,345 as of August 31, 2013, compared to 

$7,516,442 as of September 1, 2012. During the Plan year, the Plan experienced a decrease in its net assets of 

$599,097. This decrease included unrealized appreciation or depreciation in the value of Plan assets; that is, the 



The Plan had total income of $63,586,167; including employer contributions of $63,403,017, losses of $47,939 from 

the sale of assets, earnings from investments of $137,386, and other income of $93,703. 

Plan expenses were $64,185,264. These expenses included $1,309,029 in administrative expenses, $79,721 in 

investment expenses, and $62,796,514 in benefits paid to participants. A total of 19,082 persons were participants in 

or beneficiaries of the Plan at the end of the Plan year, although not all of these persons had yet earned the right to 

receive benefits at this time. 


Condensed Financial Statement 

Beginning Balance As of 09/01/2011 144 Gf 09/01/2012 


Employer Contributions $58,569,838 .$63,403,017 

Investments - Earnings $772,685 $137,386 

Sale of Assets - Earnings/Losses -$200,128 -$47,939 

Other Income $91,190 $93,703 


Benefits Paid $57,605,017 . $62,796,514 



Total Expenses $59,320,004 $64; 1&5.264 

Ending Balance As of 08/31/2012 A8 of 0813112013 


You have the right to receive a copy of the full annual report, or any part thereof, on request The following items are 

included in that report: 1) An accountant's report, 2) Assets held for investment; and 3) Transactions in excess of five 

percent of Plan assets. 


Page 40



The report provided is a summary of the annual report filed for the Carpenters Vacation and Holiday Trust Fund for 

Northern California. To obtain a copy of the full annual report or any part thereof, write or call the Carpenter Funds 

Administrative Office of Northern California, Inc., which is the Fund Manager appointed by the Plans· Administrator, 

265 Hegenberger Road, Suite 100, Oakland, California 94621; telephone (888) 547-2054. The charge to cover 

copying costs will be $15.00 per full annual report, or $.25 per page for any part thereof. 












AVISO 

Si usted tiene dificultad en entender alguna parte de este folleto, comunfquese con Carpenter Funds 


8:00a.m. a 5:00 p.m .• lunes a viemes. Usted tambien puede !lamar a Ia oficina del Plan, telefono 888-547- 


Page 41



(Enrollees of the Self Direct Investment Option) 

and 


Disclosure Document 

As of May 31, 2014 

Page 42 

This document includes important information to help you carefully compare the investment options available under your retirement Plan(s). To comply with federal 

regulations this information, which contains retirement plan fee information, is being distributed for participant directed individual account plans. If you have not 

elected to self-direct investments in your Annuity Account or have not enrolled in the Northern California Carpenters 401(k) Plan, these investment options and fees do 

not apply. 

If you would like additional information about options to self-direct investments in your individual Carpenters Annuity Plan account or information regarding 

participation in the Northern California Carpenters 401(k) Plan, please contact New York Life Retirement Services or the Carpenter Funds Administrative Office - Benefit 

Services Department at: 

:> New York Life Retirement Plan Services ("New York Life"): 

www.mylife.newyorklife.com or call1(800) 294-3575 from 8:00a.m. to 10:00 p.m. Eastern time on New York Stock Exchange business days 

:> Carpenter Funds Administrative Office of Northern California ("Fund Office") 265 Hegenberger Road, Suite 100, Oakland, California 94621 

www.carpenterfunds.com or call1(888) 547-2054 or email: benefitservices@carpenterfunds.com 

Si tiene preguntas acerca de esta informacion, llame at 1(888) 440-0022. Los Agentes de servicio a los participantes estan disponibles de 10:00 a.m. a 8 p.m. Hera del 

Este, todos los dras habiles de Ia Balsa de Valores de Nueva York. Para protecci6n suya, todas las llamadas a nuestros agentes son grabadas. 

DOCUMENT SUMMARY 

This document has three parts. Part I consists of performance information for the Plan(s), investment options available, and information regarding how well the 

investments have performed in the past. Part II provides the fees and expenses you will pay if you invest in an option. Part Ill provides Plan related information 

applicable to each of the Plans. 

Group 1/Act.ive/A&R

- ~- -- 


May31,2014 Carpenters Annuity Trust Fund for Northern California & Northern California Carpenters 401(k) Plan Group 1/Actlve/A&R 

PART I- PERFORMANCE INFORMATION 

The information in this table focuses on the performance of investment options that do not have a fixed or stated rate of return. It shows how these investments have performed 

over time and allows you to compare them with appropriate benchmarks for the same time periods. Information about an option's principal risks is available through the following 

website, myllfe.newyorklife.com/inve5tment jnfo. To view the investment option details for your Plan(s), please enter the following code: 

Code "L01505" for the Annuity Plan 

Code "'L01502" for the 401(k) Plan 

Total returns include changes in share price and reinvestment of all dividends and capital gains, if any, but not the effect of any sales charges, which are waived for qualified 

retirement plans. If sales charges were included, total returns would be lower. 

For funds with redemption fees, performance shown does not reflect the deduction of this fee which would reduce performance. Investment options are grouped according to 

investment objective. Within each investment objective grouping, funds are listed in alphabetical order. For more speciflc information, please refer to the investments' specific 

disclosure information. 

Page 43 

Performance data quoted represents past performance. Past performance does not guarantee how the Investment option will perform In the future; and due to market 

volatility, current performance may be less or higher than the figures shown. For the most recent month-end performance information, please log onto mvtife.newvqrklife.c:om 

or call a New York Life representative at 1(800)294-3575. 

:. ~~a~~~t~~~~~g~~~ ~~ ~,~~:-,~_-: ----_·:-,.. __ , I:_.-: -~ .-~~~:~ - ~·(r.~- 

INVESTMENT NAME/COMPARATIVE BENCHMARK 

- ' - - . . - 

Income 

AllianceBemstein Global Bond Fund (Advisor Class).,. 

BENCHMARK: Citigrqup World Government Bond lndex 22 

Fidelity Advisor Strategic Income Fund (Class I) 1 

BENCHMARK: Merrill Lynch U.S. High Yield 

Prudential High-Yield Fund (Class Z) 

BENCHMARK: CSFB High Yield lndex 12 

RidgeWorth Total Return Bond Fund (I Shares).,, 

BENCHMARK: Barclays US Aggregate Bond lndexm 

- - ~ 

- - -- -- 

Asset Allocation 

Goldman Sachs Satellite Strategies Portfoho (Institutional Oass) d.h 

BENCHMARK: Dow Jones 60" Global Portfoho lndextt 

Target Date - - - · ----- · 

TICKER 

ANAYX 

FSRIX 

PHYZX 

SAMFX 

GXSIX 

CURRENT RETURNS 

AS OF 0513112014 

f 3 

MONTH MONTH YTD 

1.08 2.05 4.43 

0.36 1.36 4.16 

1.37 2.67 5.07 

1.00 1.93 4.74 

0.89 1.75 4.48 

0.90 1.83 4.67 

1.46 2.32 4.78 

1.14 1.82 3.87 

2.15 3.90 5.43 

1.62 1.91 3.77 

STANDARD RETURNS 

AS OF 03/3112014 

1 3. 5 10 SINCE INCEP110N 

YEAR YEARS YEARS YEARS INCEPTION DATE 

-0.31 4.11 9.03 N/A 5.28 11/05/2007 

1.37 1.91 3.84 4.23 4.11 

2.72 5.24 11.12 6.87 N/A 07,()3/1995 

7.57 8.71 18.19 8.54 N/A 

7.53 8.62 16.21 8.32 N/A 03,()1/1996 

7.67 8.92 17.46 8.39 N/A 

-0.31 4.36 5.28 4.95 N/A 12/30/1997 

-0.10 3.75 4.80 4.46 N/A 

3.70 4.89 14.95 N/A 2.15 03/30{1007 

11.05 8.00 14.38 6.86 5.54 

The "target date" in a target date fund Is the approximate date an investor plans to start withdrawing money. The funds generally shift to a more conservative investment mix over time. Earnings 

and principal value are not guaranteed at any time Including the target date. Small and mid-cap stocks are often more volatile than large-cap stocks. Growth stocks may be more volatile than 

other stodcs because they are generally more sensitive to Investor perceptlor•s and market moves. The principal risk of Investing in value funds is that the price of the security may not approach 

its anticipated value. Foreign securities can be subject to greater risks than U.S. Investments, including currency fluctuations, less liquid trading markets, greater price volatility, political and 

economic instability, less publicly available information, and changes in tax or currency laws or monetary policy. These risks are 6kely to be greater for emerging markets than In developed 

markets. Funds that Invest In bonds are subject to Interest rate risk and can lose principal value when Interest rates rise. 

Pensionmark Asset Allocation 2015 1.32 1.97 3.85 4. 71 N/ A N/ A N/ A 6.34 11,()9/2012 

BENCHMARK: Morningstar Lifetime Moderate 2015 Index' 1.53 2.50 4.71 

8.47 7.67 13.68 7.33 10.84 

Pensionmark Asset Allocation 2020 

1A3 

BENCHMARK: Morningstar Lifetime Moderate 2020 Index" 159 

Pension mark Asset Allocation 2025 1.54 

BENCHMARK: Morningstar Lifetime Moderate 2025 Index" 1.67 

2.02 3.86 

2.62 4.81 

2.07 3.87 

2.73 4.82 

6.31 

10.17 

7.85 

12.34 

N/A N/A N/A 8.27 1l,Al9/20U 

8.25 15.21 7.66 13.06 

N/A N/A N/A 10.16 11,U9/20U 

8.92 16.83 7.94 15.90

ERISA - Plan May31, A/R 2014 1/13/2015 

Carpenters Annuity Trust Fund for Northern CalifOrnia & Nordlern California Carpenters 401(k) Plan Group 1/Act.ive/A&R 

f~ ~ - ..- - :"'~~.7-: ' "':"!'''"'';'"' ,_ : ::.-:: ···~ ;-. ~-:- ~----:::-;:.--:-.-~ -.... . . ' . ~ ...- -..-• .,.______ . .... ~,....,~ .....';'. -": · ·~ - -:--· o;w 

i Y!ltiablc:Uta~ t.~stme!lt$.;-:Av~-~ge AQrt~~l't~1 ~rn$ l"l · · . . . ' :::: , .~-. . . · , - 

~- - . . .• , •. .' .J,' •.• • ~- · ........... ~ ~ .u··~=~ -- -- ." ... · -":'·- ·-,. --· ' ... •. _ . . ...,.,. _ · . ... ~, . ·!.J. •• •!_,, _ , ..; : ... l . . 

INVESTMENTNAME/COMPARATIVEBENCHMARK 

Pension mark Asset Allocation 2030 

BENCHMARK: Morningstar Lifetime Moderate 2030 Index• 


BENCHMARK: Morningstar lifetime Moderate 2035 Index" 


BENCHMARK: Morningstar Lifetime Moderate 2040 Index" 


BENCHMARK: Morningstar Lifetime Moderate 2045 Index'" 

Pensionmark Asset Allocation 2050 

BENCHMARK: Morningstar Lifetime Moderate 2050 index 11 

Pension mark Asset Allocation Income 

BENCHMARK: Morningstar Lifetime Moderate Income Index• 

TICKER 

-- ,..---,-;:-:· . ~--- ':·----....-~~--~--------------·------. 

CURRENT RETURNS 

AS OF 05131/2014 

1 3 


1.73 2.24 4.13 

1.73 2.81 4.73 

1.81 2.25 4.06 

1.78 2.86 4.62 

1.90 2.28 4.05 

1.80 2.89 4.54 

1.99 2.31 3.97 

1.81 2.90 4.51 

2.10 2.36 3.99 

1.81 2.92 4.50 

1.22 1.91 3.84 

1.36 2.05 3.98 

1 

YEAR 

9.23 

14.51 

10.86 

16.05 

12.55 

16.72 

14.08 

16.75 

15.35 

16.61 

3.19 

5.20 

STANDARD RETURNS 

AS OF 03131/2014 

3 5 10 SINCE INCEPTION 

YEARS YEARS YEARS INCEP110N DATE 

N/A N/A N/A 11.92 11,()9/2012 

9.57 18.15 8.18 18.75 

N/A N/A N/A 13.90 11,{l9/2012 

10.02 18.94 8.35 20.76 

N/A N/A N/A 15.97 11,(19/2012 

10.18 19.25 8.47 21.67 

N/A N/A N/A 17.93 11,()9/2012 

10.09 19.30 8.51 21.72 

N/A N/A N/A 19.65 11,(19/2012 

9.95 19.28 8.54 21.58 

N/A N/A N/A 4.51 11,.tl9/2012 

5.98 9.90 6.12 6.96 

Page 44 

American Funds- American Mutual Fund (Class R5) b,o: 

BENCHMARK: S&P 500 lndex 24 

Gateway Fund (Class A) • 

BENCHMARK:S&P 500 Index>< 

Oppenheimer Real Estate Fund (Class V) 

BENCHMARK: NAREIT Equity Index 

RidgeWorth Mid-Cap Value Equity Fund (I Shares) 

BENCHMARK: Russell Midcap Value lndex 11 

Vanguard 500 Index Fund (Signal Shares) 

BENCHMARK:S&P 500 Index" 

• -- -+ - - - • 

Growth 

AllianzGI NFJ Small-cap Value Fund (Institutional Class) 

BENCHMARK: Russell 2000 Value Index" 

Delaware Smid Cap Growth Fund (Institutional Class) • 

BENCHMARK: Russell 2500 Growth lndex 19 

Eagle Small cap Growth Fund (Class R5) .._. 

BENCHMARK: Russell 2000 Growth Index" 

JPMorgan Large Cap Growth Fund (Class R5) b 

BENCHMARK: Russell 1000 Growth lndex 15 

Vanguard Mid-Cap Index Fund (Signal Shares) 

BENCHMARK: MSCI US Mid cap 450 Index 

Vanguard Small-Cap Index Fund (Signal Shares) 

BENCHMARK: MSCI US Small Cap 1750 Index 

RMFFX 

GATEX 

OREVX 

SMVTX 

VIFSX 

PSVIX 

DFDIX 

HSRSX 

JLGRX 

VMISX 

VSISX 

2.11 4.49 4.91 

2.35 3.97 4.97 

0.86 1.96 1.71 

2.35 3.97 4.97 

2.28 6.46 15.77 

2.91 6.37 15.02 

3.33 4.97 6.97 

1.67 3.66 7.42 

2.34 3.96 4.95 

2.35 3.97 4.97 

1.04 2.39 2.45 

0.63 -0.74 -0.21 

0.58 -5.28 -7.85 

1.32 -4.33 -1.23 

-().27 -7.96 -5.01 

0.97 -6.58 -3.75 

4.03 -2.83 1.00 

3.12 2.08 4.28 

2.32 1.17 4.77 

2.29 1.46 5.25 

1.20 -1.46 1.42 

0.83 -2.54 0.21 

18.21 

21.86 

5.09 

21.86 

5.35 

3.25 

22.03 

22.95 

21.80 

21.86 

18.20 

22.65 

22.35 

26.66 

22.16 

27.19 

23.34 

23.22 

23.65 

24.52 

25.28 

26.27 

13.82 19.03 7.84 N/A 05/15/2002 

14.66 21.16 7.42 N/A 

4.60 6.97 4.01 N/A 12,.tl7/1977 

14.66 21.16 7.42 N/A 

9.91 28.27 8.78 N/A 10,.tl1/2003 

10.40 28.31 8.27 N/A 

12.58 24.99 11.59 N/A 11/30/2001 

15.17 26.35 10.24 N/A 

14.62 21.15 N/A 6.88 09/29/2006 

14.66 21.16 7.42 6.84 

11.60 22.25 11.01 N/A 10,()1/1991 

12.74 23.33 8.07 N/A 

12.26 25.87 10.27 N/A 11,()9/1992 

13.93 25.82 9.64 N/A 

12.12 25.53 N/A 10.38 10/02/2006 

13.61 25.24 8.87 9.61 

13.05 N/A N/A 20.77 04/14/2009 

14.62 21.68 7.86 20.29 

13.60 25.05 N/A 7.45 03/30/2007 

14.07 25.37 10.09 7.66 

14.34 26.80 N/A 8.58 12/15/2006 

14.60 26.94 9.93 8.57


May31, 2014 

! Vf~bi ___ i~~~~;,,.Ob{~("l . -~;~_ ... -.,. 

. - .1~ -~: ....: .. _· · . \ .L- --- ..:;.... .. - . . ·.~~- ---. !..... 

INVESTMENT NAME/COMPARATIVE BENCHMARK 

- • ·- ~ - - - - ~ - -= - 

lnternationa I 

American Funds- EuroPaclfic Growth Fund (Class R5) • 

BENCHMARK: MSCI EAFE index" 

MFS International Growth Fund (Class R4) 

BENCHMARK: MSO EAFE Index" 

MainStay ICAP International Fund (Class 1) 

BENCHMARK:.MSO EAFE lndexzt 

Oppenheimer Developing Markets Fund (ClassY) 

BENCHMARK: MSCI Emerging Markets Free Index" 

Carpenters Annuity Trust Fund for Northern California & Northern California Carpenters 401(k) Plan 

TICKER 

RERFX 

MGRVX 

ICEUX 

ODVVX 

:r---- 

·' · 

... -: · . ··: .. , 

,. ·-·- 

..:.:~ ·,' 

CURRENT RETIJRNS 

AS OF 0513112014 

1 3 


2.17 1.21 2.70 

1.62 2.44 3.78 

1.65 3.25 2.63 

1.62 2.44 3.78 

1.45 2.09 3.03 

1.62 2.44 3.78 

4.22 6.32 2.53 

3.26 6.34 2.49 

·-------···-... ·-:···· 

···---·._,'i:,., . -- . • • . 

-~

ERISA - Plan May31,2014 A/R 1/13/2015 

Carpenters Annuity Trust Fund for Northern CaRfornia Be Northern California Carpenters 401(k) Plan Group 1/Active/A&R 

Page 46 

'The· Morningstar Ufetime Moderate 2035Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities and TIPS. This portfolio is held in proportions appropriate for a U.S. investor 

who is about 25 years away from retirement. The Moderate risk profile is for investors who are comfortable with average exposure to equity market volatility. An investment cannot be made directly into an index. 

"The Morningstar Ufetime Moderate 2040 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities and TIPS. This portfolio is held In proportions appropriate for a U.S. investor 

who is about 30 years away from retirement. The Moderate risk profile is for investors who are comfortable with average exposure to equity market volatility. An Investment cannot be made directly into an index. 

••The Morningstar Lifetime Moderate 2045 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities and TIPS. This portfolio is held in proportions appropriate for a u.s. 

investor who is about 35 years away from retirement. The Moderate risk profile is for investors who are comfortable with average eKposure to equity market volatlUty. An investment cannot be made directly into an index. 

11 

The Morningstar Lifetime Moderate 2050 Index represents a portfolio of global equities, bonds and traditional inflation hedges such as commodities and TIPS. This portfolio is held in proportions appropriate for a U.S. 

Investor who is about 40 years away from retirement. The Moderate risk profile is for investors who are comfortable with average exposure to equity market volatility. An investment cannot be made directly into an index. 

12 

CSFB High Yield Index: The Credit Suisse First Boston (CSFB) High Yield Index is a market-weighted index that includes publicly traded bonds rated below BBB by S&P and Baa by Moody's. Results assume the reinvestment of 

all capital gain and dividend distributions. An investment cannot be made directly into an index. 

"The Dow Jones 60% Global Portfolio Index is a benchmark designed for asset allocation strategists who are willing to take 60% of the risk of the global securities market. It Is a total returns index that is a time-varying 

weighted average of stocks, bonds, and cash. The Index is rebalanced monthly. It is not possible to invest directly in an index. 

"MSCI Emerging Markets Free Index is an unmanaged index of a sample of companies representative of the market structure of 26 Emerging Markets countries. Results assume the reinvestment of all capital gain and dividend 

distributions. An investment cannot be made directly into an index. 

" Russell 1000 Growth Index: The Russell 1000 Growth Index is an unmanaged index that measures the performance of those Russell 1000 companies with higher price-to-book ratios and higher forecasted growth values. 

Results assume the reinvestment of all capital gain and dividend distributions. An Investment cannot be made directly into an index. 

" Russell 2000 Growth Index: The Russell 2000 Growth Index is an unmanaged index that measures the performance of those Russell 2000 companies with higher price-to-book ratios and higher forecasted growth values. 

Results assume the reinvestment of all capital gain and cfrvidend distributions. An Investment cannot be made directly into an index. · 

" Russell 2000 Value Index: The Russell 2000 Value Index is an unmanaged index that measures the performance of those Russell 2000 companies with lower price-to-book ratios and lower forecasted growth values. Results 

assume the reinvestment of all capital gain and dividend distributions. An investment cannot be made directly into an index. 

11 

Russell Midcap Value Index: A market-weighted total return Index that measures the performance of companies within the Russell Midcap Index having lower price-to-book ratios and lower forecasted growth values. The 

Russell Midcap Index includes firms 201 through 1000, based on market capitalization, from the Russell 3000 Index. The Russell 3000 Index represents 98% of the of the investable US equity market. An investment cannot be 

made directly into an index. 

"Russell 2500 Growth Index: The Russell 2500 Growth Index is an unmanaged index that measures the performance of those Russell 2500 companies with higher price-to-book ratios and higher forecasted growth values. 

Results assume the reinvestment of all capital gain and dividend distributions. An investment cannot be made directly into an index. 

20 

Barclays US Aggregate Bond Index: The Barclays US Aggregate Bond Index is an unmanaged market value-weighted performance benchmark for investment-grade or better fixed-rate debt issues, including government,. 

corporate, asset-backed, and mortgage-backed securities, with maturities of at least one year. Results assume the reinvestment of all capital gain and dividend distributions. An investment cannot be made directly into an 

index. 

"MSCI EAFE Index: The MSCI EAFE Index (Europe, Australasia, Far East) is a free float-adjusted market capitalization index that is designed to measure the equity market performance of developed markets, excluding the US & 

Canada. The MSCI EAFE Index consists of the 22 developed market country indices in Europe, Australasia and the Far East. Results assume the reinvestment of all capital gain and dividend distributions. An investment cannot 

be made directly into an index. 

"The Citlgroup World Government Bond Index (WGBI) is market capitalization weighted and tracks total returns of government bonds in 22 developed countries globally. Local bond market returns are from country subindexes 

of the Citigroup WGBI. It includes reinvested interest. One cannot invest directly in an index, nor is an index representative of the Fund's portfolio. 

"S&P 500 Index TR: S&P 500 8 is a trademark of The McGraw-Hill Companies, Inc. The S&P 500 is an unmanaged index and is widely regarded as the standard for measuring large-cap U.S. stock market performance. Results 

assume the reinvestment of all capital gain and dividend distributions. An investment cannot be made directly into an index. 

An investment cannot be made directly into an index. 

The mutual fund performance and statistical data included here Is supplied by Morningstar, Inc. and was collected from company reports, financial reporting services, periodicals and other sources 

believed to be reliable. Although carefully verified, data are not guaranteed by Morningstar, Inc. or New York Life Investment Management LLC. 

Returns for 1-month, 3-month and YTD are cumulative total returns. Returns for 1-year, 3-years, 5-years, 10-years and since inception are average annual total returns through the most recent 

calendar quarter. 

The following Information focuses on the performance of Investment options that have a fixed or stated rate of return. This table shows the annual rate of return of each such option, the term or 

length of time that you will earn this rate of return, and other lnfonnation relevant to performance. 

NAME/TYPE OF OPTION 

-- - . -- -- ~ - - - 

Stable Value 

NYL Guaranteed Interest Account 1 

myli[e.newyorkli[e.com/lnvestmencinfo 

'This option is not a mutual fund. 

RETURNS TERMS OTHERS 

1.9% Semi-Annual Rate credited through 06/30/2014

-- 


As of May 31, 20143 

Page 47 

PART II- FEE AND EXPENSE INFORMATION 

Carpenters Annuity Trust Fund for Northern tallfomia- Northern tallfomla Carpenters 401(k) Plan 

The following table shows fee and expense information for the plan's investment options. The Total Annual Operating Expenses are expenses that reduce the rates of return of the investment option. 

This table also shows any redemption fees charged by an investment option upon the sale or exchange of shares and the minimum number of days one must hold the investment in order to avoid a 

redemption fee. Expense ratio (gross) does not include fee waivers or expense reimbursements which result In lower actual cost to the investor. 

r~ ;~~~;:· --------------------~----------~ 

.. ·. . . . ~ .._ . . 

TOTAL ANNUAL OPERATING EXPE.NSE 

REDEMPllON FEES 

NAME/TYPE OF OPTION As a% Per$1,000 % #Days Add"rtional Information 

- ~- 

Stable Value 

- ~ ------- 

NYL Guaranteed Interest Account 0.50% $5.00 N/A N/A 

- ~ 

- ~ - 

-- -- 

Income 

AllianceBernstein Global Bond Fund (Advisor Class) 0.64% $6.40 N/A N/A 

Fidelity Advisor Strategic Income Fund (Oass I) 0.75% $7.50 N/A N/A 

Prudential High-Yield Fund (CiassZ) 0.58% $5.80 N/A N/A 

RidgeWorth Total Return Bond Fund (I Shares) 0.41% $4.10 N/A N/A 

- ---- - ---- - - - --- - ---- . - . - - 

Asset Allocation 

Goldman Sachs Satellite Strategies Portfolio (Institutional Class) 1.10% $11.00 N/A N/A 

. - - - - - 

Target Date 

Pensionmark Asset Allocation 2015 0.55% $5.50 N/A N/A 


Penslonmark Asset Allocation 2025 0.54% $5.40 N/A N/A 



Pension mark Asset Allocation 2040 0.52% $5.20 N/A N/A 



TOTAL ANNUAL OPERATING EXPENSE 

REDEMPTION FEES 

NAMEITYPE OF OPTION As a% Per$1,000 % #Days Addmonal lnronnation 

Pension mark Asset Allocation Income 

- - - - -- __._ - 

0.55% $5.50 N/A N/A 

Growth & Income 

American Funds- American Mutual Fund (Class RS) 0.36% $3.60 N/A N/A 

Gateway Fund (Class A) 1.03% $10.30 N/A N/A 

Oppenheimer Real Estate Fund (ClassY) 1.22% $12.20 N/A N/A 

RldgeWorth Mid-Cap Value Equity Fund (I Shares) 1.09% $10.90 N/A N/A 

Vanguard 500 Index Fund (Signal Shares) 0.05% $0.50 N/A N/A 

w • ~. - - 

- 

Growth 

l'~.- .,.1 

c · -•. e 

AllianzGI NFJ Small-Cap Value Fund (Institutional Class) 0.86% $8.60 N/A N/A 

Delaware Smid Cap Growth Fund (Institutional Class) 0.94% $9.40 N/A N/A 

Eagle Small cap Growth Fund (Class RS) 0.77% $7.70 N/A N/A

ERISA - Plan As of A/R May 1/13/2015 31, 20143 

-- ~ -- - - - - ~ --- - --- - --- -~---- - 

Growth 

--- ~~-·-~--- 

JPMorgan Large Cap Growth Fund (Class RS) 0.76% $7.60 N/A N/A 

Vanguard M id-Cap Index Fund (Signal Shares) 0.09% $0.90 N/A N/A 

Vanguard Small-Cap Index Fund (Signal Shares) 

-- - - - 

0.09% $0.90 N/A N/A 

International 

American Funds- EuroPacific Growth Fund (Class R5) 0.55% $5.50 N/A N/A 

MFS International Growth Fund (Class R4) 1.07% $10.70 N/A N/A 

MainStay ICAP International Fund (Class I) 1.02% $10.20 N/A N/A 

Oppenheimer Developing Markets Fund (ClassY) 1.06% $10.60 N/A N/A 

The cumulative effect of fees and expenses can substantially reduce the growth of your retirement savings. Visit the Department of Labor's Web site for an example showing the long-term effect of fees 

and expenses at http:/ /www.dol.gov/ebsa/publlcations/401_employee.html. Fees and expenses are only one of many factors to consider when you decide to invest in an option. You may also want to 

think about whether an investment In a particular option, along with your other investments, will help you achieve your financial goals. 


PART Ill- PLAN RELATED INFORMATION 

Page 48 

Plan Administrative Expenses 

In addition to the total annual operating fees associated with the investments, an annual administrative fee of approximately 0.31% will be paid by each participant. The fee is 

deducted from individual account balances on a pro-rata basis each quarter. As an example if you have an account balance of $50,000 you will pay a quarterly fee of approximately 

$38.75 each quarter. 

The Carpenters Annuity Plan may pay outside service providers for administrative services rendered during the year, such as record keeping and investment advisory services. Such 

amounts may be paid from a segregated account under the Annuity Plan and/or may be charged against participants' accounts on a pro-rata basis in accordance with the 

Amended and Restated Rules and Regulations of the Plan. Any amounts assessed against your account will be disclosed on a quarterly basis. 

Restricted Investments 

The following funds have restrictions as described below: 1) Trustee Directed Option: This investment may have restrictions regarding contributions and liquidations. 2) Mutual 

funds are not appropriate for frequent trading and most mutual funds monitor and restrict such activity. If you conduct transactions in a particular fund too often or attempt to 

exchange among related funds soon after purchasing, the mutual fund may restrict or deny future purchases. Please review the funds' prospectuses for more information. 

Ability to Direct Investments 

"Qualified" Participants have the option of selecting their own investment options from a select group of mutual funds. In order to become a qualified Participant, you must 

participate in a special education program to learn more about selecting your own investment options. Once qualified, you have the right to transfer into or out of any Investment 

option in your Carpenters Annuity Plan at any time. Investment options in your Annuity Plan may have implemented restrictions such as short-term trading fees and/or trading 

blackout periods on certain transactions. If these apply to any of the options in the Annuity Plan, they will be explained in the Fees and Expenses section. To change any of your 

investments, you can go to mylife.newvorklife.com at any time, or you can call New York Life at 1(800)294-3575 from 8:00 a.m. to 10:00 p.m. Eastern time on New York Stock 

Exchange business days. For your protection, all calls to a New York Life Representative are recorded. 

u1 1


As of May 31, 20143 


Carpenters Annuity Trust Fund for Northern california- Northern california Carpenters 40l(k) Plan 

Plan Administrative Expenses 

In addition to the total annual operating fees associated with the investments, an annual administrative fee of approximately 0.51% will be paid by each participant. The fee is 

deducted from individual account balances on a pro-rata basis each quarter. As an example if you have an account balance of $50,000 you will pay a quarterly fee of approximately 

$63.75 each quarter. In addition partidpants in the Plan pay an annual Fund Office Fee of $120. This fee is deducted from your account at a rate of $10 on a monthly basis. 

The Northern California carpenters 401(k) Plan may pay outside service providers for administrative services rendered during the year, such as recordkeeping and investment 

advisory services. Such amounts may be paid from a segregated account under the 401(k} Plan and/or may be charged against participants' accounts on a pro rata basis or as a 

spedfic dollar amount. Any amounts assessed against your account will be disclosed on a quarterly basis. 

Participant Expenses 

The following expenses apply to all participants in the Northern California Carpenters 401(k) Plan if used by the participant. If any of these expenses apply to you, they will appear 

on your quarterly account statement. For more information regarding these expenses please refer to your Northern California Carpenters 401(k) Summary Plan Description (SPD). 

The SPD can be obtained by contacting New York life. Definitions of each of these expenses are included in the glossary described above and available at mylife.newyorklifc.com. 

Loan Fees $100 

Hardship Withdrawal Fee $75 

Insufficient Funds Fee $25 

Page 49 

Abllltv to Direct Investments 

You have the right to transfer into or out of any investment option in your Northern California Carpenters 401(k) Plan at any time. Investment options in your 401(k) Plan may have 

implemented restrictions such as short-term trading fees and/or trading blackout periods on certain transactions. If these apply to any of the options in the 401(k) Plan, they will 

be explained In the Fees and Expenses section. To change any of your investments, you can go to myllfe.newvorkllfe.com at any time, or you can call New York Life at 1(800} 294- 

3575 from 8:00a.m. to 10:00 p.m. Eastern time on New York Stock Exchange business days. For your protection, all calls to a New York life Representative are recorded • 

... 

About Risk 

All Investing involves risk. It is possible that your Investment objectives may not be met. All mutual funds are subject to market risk and may fluctuate In value. Neither New York 

life Investment Management LLC, its affiliates nor its representatives, provide tax, legal or accounting advice. Please contact your own advisors. 

Please contact New York Life at 1(800) 294-3575 for a prospectus, and, If available, a summary prospectus. 

Investors are asked to consider the Investment objectives, risks, and charges and expenses of the investment carefully before investing. 

The prospectus, or summary prospectus, contains this and other Information about the investment company. 

Please read this information carefully before investing. 

Securities are distributed by NYLIFE Distributors LLC, 169 Lackawanna Avenue, Parsippany, NJ 07054. 

New York life Retirement Plan Services Is a division of New York Ute Investment Management LLC. NYLIM-22344 

AVISO 

Si usted tiene dificultad en entender alguna parte de este folleto, comunfquese con Carpenter Funds Administrative Office en 265 Hegenberger Road, Suite 100, Oakland, CA 94621. 

Las horas de oficina son de 8:00a.m. a 5:00p.m., lunes a viemes. Usted tam.bien puede llamar a Ia oficina del Plan, telefono 888-547-2054, para ayuda.


Carpenters Health & Welfare Trust Fund for California: Plans A&R coverage Period: 09/01/2014- OS/31/2015 

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family I Plan Type: PPO 

This is only a summary. If you want more detail about your covetage and costs, you can get the complete t.enns in the policy oi: plan 

document at WWW•Cru;pe!nterfunds.com M by ~ 1-8~~~54!~~05~ .... _ _ __ ·- _ . .. __ .... __ . --· ·- ·-- 

Page 5 

What is the overall 

deductible? 

·· . PPO Provider. $100/ person per calendar year; $200/fanuly per 

calendar rear. Non-PPO Provider: $200 /person pet calendar 

. 

. y u must pay all the costs up to the deductible amount before 

year; $400/ family per calendar year. Does not apply to mental this. plan begms to pay for covered services you use. Check your 

health, chemical dependency (including detox), member assistance policy

Carpenters Health & Welfare Trust Fund for California: Plans A&R Coverage Period: 09/01/2014-08/31/2015 

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family I Plan Type: PPO 


• Copayments are fixed dollar amounts (for example, $15) you pay foi: covered health care, usually when you receive the service. 

• Coinsurance is .J0111" share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's 

allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met 

your deductible. 

• The amount the plan pays for covered services is based on the allowed amount. If an oU:t'-of-netwark provider charges more than the allowed 

amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed 

amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) 

• This plan may encourage you to use PPO providers by charging you lower deductibles, copayments and coinsurance amounts. 

- - -- 

10% coinsurance after deductible met. 

30% coinsurance after 

deductible met. 

Services must be medically necessary 

and are subject to plan limitations. 

Page 6 

If you visit a health care 

proyidet's office or cliuic 

Other practitioner 

office visit 

Preventive 

care/ screening/ 

Chiropractic: After deductible, 10% 

coinsurance and fees over the Plan's 

maximum payment of $25/visit. 

Acupuncture: After deductible, 10% 

coinsurance and fees over the Plan's 

maximum payment of$35/visit. 


Chiropractic: After 

deductible, 30% 

coinsurance and fees over 

the Plan's maximum 

payment of $25/visit. 

Acupuncture: After 

deductible, 30% 

coinsurance and fees over 

the Plan's maximum 

n~vmPntof 



Chiropractic: 20 visits/ calendar year 

(Chiropractic coverage limited to 

employee and spouse only). 

Acupuncture: 20 visits/ calendar year. 

For children over age 2, benefits are 

limited to one exam in any 12-month 

If you have a test 

Imagjng (CT /PET 

scans, MRis) 

-~- 





and are sub1ect to olan limitations. 

Pre-authorization is required for 

Cf /CIA, MR.!, Nuclear Cardiology, 

Pet Scans and Echocardi02taphy. 

Questions: Calll-888-547-2054 or visit us at www.carpenterfunds.com If you aren't clear about any of the underlined terms used in this fottn, see the 

Glossary. You can view the Glossary at www.carpenterfunds.com or: www.dolgov/ebsa/healthreform or call1-888-547-2054 to request a copy. 2 of 8


Carpenters Health & Welfare Trust Fund for California: Plans A&R Coverage Period: 09/01/2014 - 08/31/2015 

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family 1 Plan Type: PPO 

II,Ou need drugs to treat 

your illness or .condition 

:More iafonnation· about 

pre$cription dmg · 

~yerage is a-nilable _&Om 

Express ~cripts at · . 

)YW$.exprsss-sg;jpts.cptn 

ot ~ 1...000-939~7093. 

Page 7 

, Hyou have outpatient 

: Surgety . 

Generic drugs 

Fotmu1aty Brand 

drugs (Preferred 

Btanddmgs) 

You pay 100% (unless 

there ate no netwot:k. 

pharmacies within 10 

miles). Plan reimbutses no 

mote than it would have 

paid had you used an Inr-·-'" 

---- ·-- ·---~ __ 

Non-fotmulaty 

brand drugs (Non 

. Preferred Brand 

drugs) 

Specia.Jty drugs 

Retail Phatmacy (30 -day supply): $60 

copaytnent; Mail Otdet (90-day 

supply): $100 copayment. 

Subject to Retail Copays (30 day 

supply). 

Facility fee (e.g., 

ambulatory surgery 

! center) . . 110% coinsmance after deductible met. 

Physician/ surgeon 

fees 

Netwot:k. Retail phannacy. 

Not covered 

No deductible applies to any 

outpatient prescription drugs. If the 

cost of the drug is less than the copay, 

you pay just the drug cost. Brand 

name Proton Pump Inhibitors (PPI) 

and Cholesterol drugs not covered 

For any new Brand Name Drug 

approved by the federal FDA, 

including injectable and infusion 

Drugs, the Copayment is 50% of the 

cost of the Drug for a minimum of 24 

months after the Drug has been 

approved If the PBM detemrines 

that the new FDA approved Drug is a 

"must not add" Drug, the Copayment 

will remain at 50% of the cost of the 

Drug. Mail Order is mandatory if 

more than 2 prescriptions ate filled 

for maintenance medications. 

Specialty drugs are available only frotn 

the PBM's Mail Order Phannacy 

(except certain emergency drugs may 

be provided by a retail Participating 

Pharmacy). 

30% coinsurance aftet . For the hospital facility clw:ge, a 

deductible met up and fee5 maximum of $6,000 is payable fot an 

over Plan's maximum of . arthroscopy, $2,000 for cataract 

$300 for ambulatory Sutglcal surgery and $1,500 for colonoscopy. 

: If you need immediate 

. medical atreaooa 

Emergency room 

services 


Services must be medically nect-..ssary 


Questions: Calll-888-547-2054 or visit us at www.carpenterfunds.com If you aren't clear about any of the underlined terms used in this form, see the 

Glossary. You can view the Glossary atwww.car,penterfunds.com or: www.dolgov/ebsa/health.reform or call1-888-547-2054 to request a copy. 3 of 8

Carpenters Health & Welfare Trust Fund for California: Plans A&R Coverage Period: 09/01/2014- 08/31/2015 



If you have a hospital 

stay 

Page 8 

If you have mental 

health, bebavioraJ .. health, 

or substance. abuse 

needs· 

If you are pregnant 

Urgent care 





Elective hospital admtssion requires 

Pre-authorization to avoid a 25% · 

I 


penalty. A maximum of $30,000 is 

hospital room) 

30% coinsurance after payable for the hospital facility chatges 

to% coinsurance after deductible met. 


associated with a single hip joint or 

knee · · 


fee 


Mental/Behavioral 

Outpatient care limited to 20 visits per 

50% coinsurance, no 

health outpatient $20 copay 

calendar year. Elective hospital · I 

deductible. 

~ servtces . admission requires Precertification or 

· 


no benefits will be paid Limited to a 

deductible. You pay 100% 

Mental/Behavioral 

for Non-PPO treatment of 

health inpatient 10% coinsurance, no deductible. 

severe mental 

services 

Substance use 

disorder outpatient 

Substance use 

disorder inpatient 

services 

Prenatal and 

care 

Delivery and all 

inpatient services 

I No charge 

I No charge 


illness/ serious emotional 

disturbance of a child. 


deductible. 


deductible. 


deductible met 

20 day maximum per calendar year 

(treatment of severe mental 

illness/ serious emotional disturbance 

ofa child with PPO providers that is 

precertified is not subject to the 

manm 

All services require precertification o.t 

no benefits are payable. 

All services require precertification or 

no benefits are payable. 

------ jjt- 


and are subiect to olan limitations. 

Precertification required only if 

hospital stay is more than 48 hours 

for vaginal delivery or 96 hours for C 

section. 


Glossary. You can view the Glossary at www.carpenterfunds.com or: www.dolgov/ebsa/healthreform or call1-888-547-2054 to request a copy. 4 of 8 

I


Carpenters Health & Welfare Trust Fund for California: Plans A&R coverage Period: 09/01/2014-08/31/2015 


Hyou need help 

recovering or have other 

special health needs 

Page 9 

Hyour child needs' 

dental or eye care 

Skilled nursing care 

~ble medical·-·· 

Hospice service 



deductible met 

Precertification is recommended. 

I .1mited to 70 days per confinement 

Services must be medically necessary · . ' 

1 

and are sub1ect 1:2Plan limitations. 

Covered if termina11y ill. Bereavement 

services (limited to 8 visits within one 

year·ofPatient's death, not to exceed 

$25 per visit), and respite care is 

limited to 8 

1--..!..--~---~ot ~overed I No! coveted _j Vision, s~ces available under a 

Glasses I Not covered TNot covered l separate vts1on plan. 

Dental check-up Not covered Not covered 

Dental seMces available under 

I 

Excluded Services & Other Covered Services: 

Services Your Plan Does NOT Cover IThis isn't a comnlete list. Check 

• Cosmetic surgety • Infertility treatment 

• Habilitation services • Lon~ term care 

,Jan document for other excluded services. 

Other Covered Services .. 

(I'bis isn't a complete list. Check yo1J1'_policy or p~an doc!J!D.ent for other covered services and your costs for these services.) 

• Acupuncture (up to 20 visits per calendar 

year) 

• Bariatric surgery 

• Chttopractic care (up to 20 visits per calendar 

year for employee and spouse only). 

• Dental care (up to $2,500 for PPO and $2,000 for Non-PPO per 

calendar year) under separate dental plan 

• Hearing aids (limited to $800/ ear in any 3 year period) 

• Non-emergency care when traveling outside the U.S. 

• Routine eye care (under 

separate vision plan) 

• Routine foot care 


Glossary. You can view the Glossary at www.carpenterfunds.com or: www.dolgov/ebsa/healthreform or calll-888-547-2054 to request a copy. 5 of 8

Page 10 

Carpenters Health & Welfare Trust Fund for California: Plans A&R coverage Period: 09/01/2014 - 08/31/2015 



---------------------------------..---------""'··-~..... ~····- ·-----------·-- ---~· ~---·--- -· ~ · 

Your Rights to Continue Coverage: 

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws tnay provide protections that allow .you to keep health 

coverage. Any such rights tnay be limited in duration and will require you to pay a premium, which tnay be significantly higher than the premium you pay 

while covered under the plan. Other limitations on your rights to continue coverage may also apply. 

For tnore infonnation on your rights to continue coverage, contact the plan at (888) 547-2054. You tnay also contact your state insurance departtnent, the U.S. 

Departtnent of Labor, Em.ployee Benefits Security Adtninistration at 1-866-444-3272 or www.dol.gov/ebsa. or the U.S. Departtnent of Health and Hutnan 

Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. 

Your Grievance and Appeals Rights: 

If you have a cotnplaint or are dissatisfied with a denial of coverage for claitns under your plan, you tnay be able to aJWeal or file a grievance. For questions 

about your rights, this notice, or assistance, you can contact the Fund Office at 1-888-547-2054. You tnay also contact the Departtnent of Labor's Etnployee 

Benefits Security Adtninisttation at 1-866-444-EBSA (3272) or www.dol.ggv/ebsa/healthrefonn. 

Does this Coverage Provide Minimum Essential Coverage? 

The Affordable Care Act requires tnost people to have health care coverage that qualifies as "tninim.um essential coverage." This Plan or policy does 

provide minimum essential coverage. 

Does this Coverage Meet the Minimum Value Standard? 

The Affordable Care Act establishes a tninim.um value standard of benefits of a health plan. The tninim.um value standard is 60% (actuarial value). This health 

coverage does meet the minimum value standard for the benefits it provides. 

Language Access Services: 

Spanish (Espaiiol): Para obtener asistencia en Espaiiol, llatne al1-888-547-2054. 

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tutnawag sa 1-888-547-2054. 

Chinese (9='X}: :tm-*~~l:f:!Jti¥JmWJ, W~~J~"}~iij 1-888-547-2054. 

----------To see examples of how this plan might cover costs f()f" a sample medical situation, see the next page.---------- 

Questions: Calll-888-547-2054 or visit us at www.car,penterfun.ds.com If you aren't clear about any of the underlined terms used in this fonn, see the 

Glossary. You can view the Glossary atwww.carpenterfunds.com or: www.dol.ggv/ebsa/healthrefonn or call1-888-547-2054 to request a copy. 6 of 8


Carpenters Health & Welfare Trust Fund for California: Plans A&R coverage Period: 09/01/2014-08/3112015 

Coverage Examples 

Coverage for: Individual+ Family! Plan Type: PPO 

About these 

Coverage Examples: 

Having a baby 

(nonnal dcln~ery) 

Managing type 2 diabetes 

(routine maintenance of 

a wcll-conrrollcd condition) 

Page 11 

These examples show how this plan might cover 

medical care in given situations. Use these 

examples to see, in general, how much financial 

protection a sample patient might get if they are 

covered under different plans. 

I 

, . This is 

I 

j 

not a cost 

estimator. 

Don't use these examples to 

estimate you:r actual costs 

under this plan. The ac:tual 

care you receive will be 

different from these 

examples, and the cost of 

that care will also be 

different 

See the next page for 

I importaot infonnatio" about 

exatnples. 

• Amount owed to providers: $7,540 

• Plan pays $6,630 

• Patient pays $910 

ts 

s - - .. ---- - 

Hospital charges (mother) $2,700 

Routine obstetric care $2,100 

Hospital charges (baby) $900 

Anesthesia $900 

Laboratory tests $500 

Prescriptions $200 

Radiology $200 

_. .Yac~~! -~~-~fe!~~- ----- ____ --.----...J~ . - 

TOOll ' · ,. . . . . . f $7,540 

-- - -------- ----~ -·---.-a..---·-·---.. ~-- - -· ·--- 4- -- --- 

Patient oavs: 

Deductibles $100 

Copays $60 

Coinsurance $720 

Limits or exclusions $30 

Total · 

--··-- 

- . . . 1 -·--$910- 

-~~ - ---- -· ··--t-. . ---- ····--' 




Sample care costs: 

Prescriptions $2,900 

Medical Equipment and Supplies $1,300 

Office Visits and Procedures $700 

Education $300 


. Va~~~.!.?.Eter p~~!:?.tivc;_ __ ~ ·- - -- ~~00 __ 

_:f.?~----· --· -- -· ·- -·--- ----- . -· · ' - j_ __ _ ~5,4!t~. 

Patient~s: 


Copays $440 


Limits or exclusions I $40 

----·---·--------·-··-·---w--l--.-w--·-- 

Total 1 $830 

Questions: Calll-888-547-2054 or visit us at www.carpetttetfunds.com If you aren't clear about any of the underlined terms used in this form, see the 

Glossary. You can view the Glossary at www.carpenterfunds.com or: www.dol.gov /ebsa/healthrefonn o:r cal11-888-547 -2054 to request a copy. 7 of 8

Carpenters Health & Welfare Trust Fund for California: Plans A&R Coverage Period: 09/01/2014- OS/31/2015 


Coverage Examples 

____________________________ , ..._ 

Questions and answers about the Coverage Examples: 

__________ ~----- 

Coverage for: Individual + Family! Plan Type: PPO 

· --·----· 

Page 12 

What are some of the 

assumptions behind the 

Coverage Examples? 

• Costs don't include premiums. 

• Sample care costs are based on national 

averages supplied by the U.S. Department 

of Health and Human Services, and aren't 

specific to a particular geographic area or 

health plan. 

• The patient's condition was not an excluded 

or preexisting condition. 

• All services and treatments started and 

ended in the same coverage period. 

• There are no other medical expenses for 

any member covered under this plan. 

• Out-of-pocket expenses are based only on 

treating the condition in the example. 

• The patient received all care from innetwork 

providers. If the patient had 

received care from out-of-network 

providers, costs would have been higher. 

What does a Coverage Example 

show? 

For each treatment situation, the Coverage 

Example helps you see how deductibles, 

copayments, and coinsurance can add up. It 

also helps you see what expenses might be left 

up to you to pay because the service or 

treatment isn't covered or payment is limited 

Does the Coverage Example 

predict my own care needs? 

~No. Treatments shown are just examples. 

The care you would receive for this 

condition could be different based on your 

doctor's advice, your age, how serious your 

condition is, and many other factors. 


predict my future expenses? 

'-~No. Coverage Examples are run cost 

estimators. You can't use the examples to 

estimate costs for an actual condition. They 

are for comparative purposes only. Your 

own costs will be different depending on 

the care you receive, the prices your 

providers charge, and the reimbursement 

your health plan allows. 

Can I use Coverage Examples to 

compare plans? 

,(Yes. When you look at the Summary of 

Benefits and Coverage for other plans, you'll 

find the same Coverage Examples. When 

you compare plans, check the ''Patient Pays" 

box in each example. The smaller that 

number, the more coverage the plan 

provides. · 

Are there other costs I should 

consider when comparing plans? 

,/'Yes. An important cost is the premium 

you pay. Generally, the lower your 

premium, the more you'll pay in out-ofpocket 

costs, such as copayments, 

deductibles, and coinsurance. You should 

also consider contributions to accounts such 

as health savings accounts (HSAs), flexible 

spending an:angements (FSAs) or health 

reimbursement accounts (HRAs) that help 

you pay out-of-pocket expenses. 

5319652v1/00573.001 

Questions: Call1~888-547-2054 or visit us at www.carpenterfunds.com If you aren't clear about any of the underlined terms used in this form, see the 

Glossary. You can view the Glossary at www.carpenterfunds.com or: www.dol.gov I ebsa/healthreform or call 1-888-54 7-2054 to request a copy. 8 of 8


Kaiser Permanente: PLANS A & R 

Summary of Benefits and Coverage: What this Plan Covers & What it Costs 

Coverage Period: 09/01/2014 - 08/31/2015 

Coverage for: Individual + Family 1 Plan Type: HMO 

This is only a summary. If you want more detail about yoltt cov~ and costs, you can get the complete terms in the policy or plan 

document at www.kp.org or by calling 1-800-278-3296. · 

What is the overaJI 

deductible? 

$0 

See Chart on page 2 for yoltt costs for services this plan covers. 

Are there other 

deductibles fot specific 

services? 

No 

You don't have to meet deductibles for specific services, but see the chart 

smrtin,g on page 2 for other costs for services this plan covers. 

Is there an out-ofpocket 

limit on my 

expenses? 

Yes, $1,500 Individual/$3,000 Family 

The out-of-pocket limit is the most you could pay during a coverage period 

(usually one year) for yoltt share of the cost of covered services. This litnit helps 

you plan for health care expenses. 

Page 13 

What is not included in 

the out-of-pocket limit? 

·.Is there an overan annual 

limit on what the plan 

pays? 

Premiums, health care this plan doesn't 

cover, and cost sharing for certain 

services listed in plan documents. 

No 

Even though you pay these expenses, they don't count toward the out-ofpocket 

limit. 

The chart starting on page 2 describes any limits on what the plan will pay for 

spedfo covered services, such as office visits. 

Does this plan use a 

network of providers? 

Yes. For a list of plan providers, see 

www.kp.org or calll-800-278-3296. 

If you use an in-network doctor or other health care provider, this plan will pay 

some or all of the costs of covered services. Be aware, your in-network doctor or 

hospital may use an out-of-network provider for some services. Plans use the 

term in-network, preferred, or participating for providers in their network See 

the chart starting on page 2 for how this plan pays different kinds ·of nroviders. 

Do I need a referral to 

see a snecialist? 

Yes, but you may self-refer to certain 

specialists. 

1bis plan will pay some or all of the costs to see a specialiot for covered services 

but only if you have the plan's pemnssion before you see the sneci 

. . 

Are there services this 

plan doesn't cover? 

Yes 

Some of the services this plan doesn't cover are listed on page 5. See your policy 

or plan document for additional information about excluded services. 

Questions: Call1-800-278-3296 or 1-800-777-1370 (fTY}, or visit US at www.kp.org. 

If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the PID:26 & 35684 

Glossary at http://www.doLgov/ebsa/pdf/SBCUniformGlossary.pdf or call1-800-278-3296 or 1-800-777-1370 (TTY) to request a copy. 


CARPENTERS HEAL1H & WELFARE lRUST FUND FOR CAliFORNIA 

1 of8


• Copayments are fued dollar atnoun~ (for e.umple~ $15) you pay for covered health care, usually when you receive the service. 

• Coin§Jttan.ce is YOIII' share of the Costs of a coveted servi~ calculated as a p~ of the aUowed amoiutt for the service. For example, if 

the plan;s allowed amount fot an overnight hoSiiliai stay is $1~000, yout coinsumnce payment of 20°/C? would be $200. This may Change if 

you haven't met yottt dedu.ctible. · 

• The aniowit the plan pays for coveted senices is b~d on. the allows«.t'amount. If an out-of-netwotk provider chatges more than the 

·allowed amount,. you may have to pay the. difference. Fot exaplpl~ if an Out-'Qf-netWo.tk hospital charges $1~500 for an overnight stay and 

the allowed amount lS $t,OOO~ you may haVe to pay the $500 difference. (ThiS is ailled balance hffiing~) 

• This plan·inay en~~ you ro, ~ plan p.rovidets by charging you low~ dedi1ctt0les, copayme11ts an4 coinsurance amounts. 

Page 14 

If you visit a 

health care 

providet's office 

or clinic 

If you have a test 

Other practitioner office 

visit 

Preventive care / 

screening/ 

immunization 

L 

----- 

Diagnostic test (x-ray, 

blood work) 

Imaging (CT /PET scans, 

l MRis) 

If you need drugs 

to treat your I Generic drugs 

illness or 

condition 

More infonnation 

about prescription j Preferred brand drugs 

drug coverage is 

available at · j Non-preferred brand 

www.kp.~/fo.ttnul · 

Primary care visit to treat 

$20 per vlsit 

---none--- 

an inj~ or ~ess _ ··----4 

Services related to Infertility covered at 

Specialist vlsit 

$20 per visit 

$20 ner vlsit 

$10 per visit for chiropractic services 

Up to 30 visits per calendar year. 

Not covered 

visit for acuounctute services 

Phv~1ci!:!n referred 

$20 per visit 

X-ray: No charge; 

Lab tests: No charge 

No charge 

$10 per prescription for 1 to 100 days 

$30 per ptescription fot 1 to 100 days 

Same as preferred brand drugs 

Not covered 

Not covered 

Not covered 

Some preventive screenings (such as lab and 

imaging) may be at a different cost share. 

--none-- 

-none-- 

In accordance with formulary guidelines, 

Not covered I certain drugs may be covered at a different 

cost share 

In accordance with · formulary guidelines, 

Not covered I certain drugs may be covered at a different 

cost share 

Not covered I Same as preferred brand drugs when apptoved 

through exception process. 

2 of8


Page 15 

Common 

Medical Event 

~ 

Services You May 

Need 

Specialty drugs 


a.tnbulatory surgery 

-none- 

lfyou&ave 

outPatient surgery '\_~ter)__-----+----. 

If you. need 

immediate• 

.medical attention 

·If yOu. have a 

hospital stay · 

·If you haVe-· 

mental health, 

beh3vioml h~ 

orsubstali.ce 

abuse needS 

If you are 

pregnant 

PhVS1ClaD./ sur~eon fees 

Emergency room 

servtces 

Emergency medical 

Urgent care 

rii;dllt1£;;c(e:g.~ hospital 

services 

Prenatal and postnatal. 

care 

Delivery and all inpatient 

servtces 

Your Cost If You Use a 1 

Plan Provider I Non-Piaili Limitations & Exceptions 

Provider I 

Sa.tne as Preferred brand drugs when approved 

Sa.tne as preferred brand drugs Not covered 

through exception process. 

$20 per procedure Not covered 

No~ 

$50 per visit 

No charge 

$20 per visit 

No charge 

No charge 

$20 pet Individual visit; 

$10 oer eroun visit 

No charge 

$20 per Individual visit, 

$5 pet group visit 

No charge 

Prenatal care: $5 per visit 

Postnatal care: $5 per visit 

No charge 

Not covered 

Not covered 

-none-- 

-none-- 

Non-Plan providers covered when outside the 

service area. 

-none--' 

Not covered 1 -none-- 

Not covered 1 -none-- 

Not coveted 1 -none-- 

Not covered 1 -none--- 

Not coveted 

Not covered 

PrenataL Cost sharing for prenatal care is for 

routine preventive care only. 

Postnatal: Cost sharing for postnatal care is 

for the first postnatal visit only. 

Not covered 1 -none- 

-none- 

-none- 

-- ~--.. ··-·----· w - ! w .w •-~• _,,.__., 

~. 

3of8


Common 

Medical Event 

Services You May 

Need 

Your Cost If You Use a 

__j 

Pla~P~~~vi~e ~ ___ _ ~~~~~~:~ I Limitations & Exceptions 

Home health care 

No charge 

- -· ·- --~ -- - 1 _ - 

Up to 2 hours maximum pet: visit. Up to 3 

Not covered I visits maximum per day, Up to 100 visits 

maximum per calendar year. 

If you need help 

recovering or have 

other special 

health needs 

Rehabilitation services 

Habilitation services 

Skilled nursing care 

Inpatient: No charge 

Outpatient: $20 per visit 

$20 per visit 

No charge 

Not covered 

Not covered 

Not covered 

---none--- 

--none--- 

Up to a 100 day maximum per benefit period 

Dutable medical 

equipment 

No charge 

Not covered 

Must be accordance with formu1ary guidelines. 

Requires prior authorization. 

Page 16 

Hospice service 

Eye exam 

No charge 

$20 per visit 

Not covered 

Not covered 

Limited to a diagnosis of terminal illness with 

a life e~ectang~~elve months or less. 

-none- 

If your child 

needs dental or 

eye care 

Glasses 

Dental check-up 

Amount in excess of a $125 allowance I Not covered 

Not covered 

Not covered 

Allowance limited to once every 24 months. 

You may have other optical coverage not 

described here. Refer to "Other Covered 

Services" for additional information. 

You may have other dental coverage not 

described here. 

Excluded Services & Other Covered Services: 

Services Your Plan Does NOT Cover (I'his isn't a complete list. Check your policy or plan document for other excluded services.) 

• Cosmetic Surgery 

• Dental care (Adult) 

• Long-tenn care 

• Non-emergency care when traveling outside 

the US 

• Private-duty nursing 

• Routine foot care unless medically necessary 

• Weight loss programs 

4of8


. . 

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and_yout costs for these · · 

services.) · · · · · ·· 

• Acupuncture (plan provider referred) • Chiropractic care • Infertility treatment 

• Bariatric surgery • Hearing aids • Routine eye care (Adult) and eyewear 

allowance (Adult) 

Your Rights to Continue Coverage: 

If you lose coverage under the plan, then, depending upon the circumstances, Federal and Smte laws may provide protections that allow you to keep health 

coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significandy higher than the premium_you 

pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue 

coverage, contact the plan at 1-800-278-3296. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits 

Security Administration at 1-866-444-3272 orwww.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or 

www.cciio.cms.gQV. 

Page 17 

Your Grievance and Appeals Rights: 

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For 

questions about your rights, this notice, or assistance, you can contact: Kaiser Permanente at 1-800-278-3296-or online at www.kp.org/memberservices. 

If this coverage is subject to ERISA, you may contact the Department of Labor's Employee Benefits Security Administration at 1-866-EBSA (3272) or 

www.dol.gov/ebsa/healthrefonn and the California Department of Insurance at 1-800-927-HELP (4357) orwww.insumnce.ca..gm:. 

Additionally, this consumer assistance program can help you file your appeal: 

Department of Managed Health Care Help Center 1-888-466-2219 

980 9th Street, Suite 500 htt,p: //www.healthhelp.ca.gov 

Sacramento, CA 95814 

helpline@d.mhc.ca.gQv 

Does this Coverage Provide Minimum Essential Coverage? 

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does 

provide minimum essential coverage. 

5 of8


Does this Coverage Meet the Minimum Value Standard? 

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This 

health coverage does meet the minimum value standard for the benefits it provides. 

Language Access Services: 

Spanish (Espaiiol): Para obtener asistencia en Espaiiol, llame al1-800-788-0616, TIY/1DD 1-800-777-1370 

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-278-3296, TIY/1DD 1-800-777-1370 

Chinese (r:f:tJt): :«o*~~r:f:t::.\'CI¥Jf:Wijb, ifttljJ)X1'~~ 1-800-757-7585, TIY/1DD 1-800-777-1370 

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-278-3296, TIY/1DD 1-800-777-1370 

-----------To see examples of how this plan might cover costs for a sample medical situation, see the next page .. ----------- 

Page 18 

6 of8


Page 19 

About these Coverage 

Examples: 

These examples show how this plan might cover 

medical care in given situations. Use these 

examples to see, in general, how much financial 

protection a. sample patient might get if they a.re 

covered under different pla.ns. 

This is 

nota cost 

estimator. 

Don't use these examples to 

estimate your actual costs 

under this plan. The actual 

care you receive will be 

different from these 

examples, and the cost of 

that care will also be 

different. 

See the nt;n page for 

important information about 

.these examples. 

Having a baby 

(normal dcli,~ ery) 

- - - - 




Sample care costs: 

Hospital charges (mother) $2,700 

Routine obstetric ca.re $2,100 

Hospital charges (baby) $900 

Anesthesia $900 


Prescriptions $200 

Radiology $200 

Vaccines, o~er e_~~~c:_·~ ---- _ _., $40_ 

' Totru · · · · · $7,540 

--·~-- ----~--- -- -- -·----··-----~1---· --·-· .... 

Patient pays: 


Copays $90 



. ToW. . . 

- 

$291 

-· -~-- ..: .. - --·- 

·------- --- ·------~·-----·---·-··---- 

Managing type 2 diabetes 

(routine maintenance of 

a well-controlled condition) 

• Amount owed to providers: $5.400 



Sam_l!le care costs: 

Prescriptions $2,900 

Medical Equipment and Supplies $1,300 

Office Vtsits and Procedures $700 

Education $300 


Vaccines, other preventive $100 

-·---- ·-..,..~---~-------- ---- ~--· · 

Total . ~ $5,400 

_ ___ .........., 

------·· - · --L----· · ·~ ·-----· 

Patient P&IYS: 


Copays $700 



· --ro";d----·-----·~---"-·--··-; -$780 "" 

·----.&.-·.... - ___... --·- - 

7 of8


Questions and answers about the Coverage Examples: 

Page 20 

What are some of the 

assumptions behind the 

Coverage Examples? 

• CostE don't include premiums. 

• Sample care costE are based on national 

averages supplied by the U.S. 

Department of Health and Human 

Services, and aren't specific to a 

particular geographic area or health plan. 

• The patient's condition was not an 

excluded or preexisting condition. 

• All services and treatmentE started and 

ended in the same coverage period. 

• There are no other medical expenses for 

any member covered under this plan. 

• Out-of-pocket expenses are based only 

on treating the condition in the example. 

• The patient received all care from innetwork 

providers. If the patient had 

received care from out-of-network 

providers, costE would have been lllgher. 

What does a Coverage Example 

show? 

For each treatment situation, the Coverage 

Example helps you see how deductibles, 

copayments, and coinsurance can add up. It 

also helps you see what expenses might be left 

up to you to pay because the service or 

treatment isn't covered or payment is limited 


predict my own care needs? 

.): No. TreatmentE shown are just examples. 

The care you would receive for this 

condition could be different based on your 

doctor's advice, your age, how serious your 

condition is, and many other factors. 


predict my future expenses? 

... N 

. . __Q. Coverage Examples are not cost 

estimators. You can't use the examples to 

estimate costE for an actual condition. They 

are for comparative purposes only. Your 

own costE will be different depending on 

the care you receive, the prices your 

providers charge, and the reimbursement 

your health plan allows. 

Can I use Coverage Examples 

to compare plans? 

Yes. When you look at the Summary of 

Benefits and Coverage for other plans, 

you'll find the same Coverage Examples. 

When you compare plans, check the 

''Patient Pays" box in each example. The 

smaller that number, the more coverage 

the plan provides. 

Are there other costs I should 

consider when comparing 

plans? 

~Yes. An important cost is the premium 

you pay. Generally, the lower your 

premium, the more you'll pay in out-ofpocket 

costs, such as copayments, 

deductibles, and coinsurance. You 

should also consider contributions to 

accounts such as health savings accounts 

(HSAs), flexible spending arrangements 

(FSAs) or health reimbursement accounts 

(HRAs) that help you pay out-of-pocket 

expenses. 

Questions: Call1-800-278-3296 or 1-800-777-1370 (fTY), or visit us at www.kp.org. 

If you aren't clear about any of the underlined terms used in this fonn, see the Glossary. You can view the 

Glossary at http://www.doLgov/ebsa/pd.f/SBCUniform.Glossaty.pd.f or call1-800-278-3296 or 1-800-777-1370 (fTY) to request a copy. 8 of 8 

CARPENTERS HEAL1H & WELFARE TRUST FUND FOR CALIFORNIA 

PID:26CNTR:t EU:N/APianiD:tt6t SBCID:t23645


Carpenters Health and Welfare Trust Fund for California - SBC Supplement for Active Kaiser Plans (2014) 

The benefits described below are provided by the Trust Fund and are in addition to the benefits provided by Kaiser. 

Substance use 

All level of Chemical Dependency 

·lfyoulu\ve,m.eatal . . disorder outpatient No charge Not coveted care (incluchng detox) require 

health, behavi~ra.l health, ·services 

precertification by OptumHealth 

or substanCe abuse · Substance use Behavioral SolutiQnS (877) 225-2267 

,r., .t•~~-.t- •-.patient Noc charge Not covered 

or no benefits are payable. 

servtces 

Page 21 

Questions: Callt-888-547-2054 or visit us at www.cfao.org. If you aren't clear about any of the underlined terms used in this form, see the 

Glossary. You can view the Glossary atwww.www.cfao.org or. www.dol.gov/ebsa/healthrefonn or calli-888-547-2054 to request a copy. 

1 of1 

Group 1/Act'Ne/A&R






(510) 633-0333 ▪ (888) 547-2054 


September 26, 2014 

TO: 

FROM: 

RE: 

All Pension Plan Participants, Pensioners, and Beneficiaries 



Notice of Plan Changes 

This notice is to inform you of changes to the terms of your Pension Plan. Please keep this notice with your June 

2012 Edition of the Pension Plan’s Summary Plan Description (SPD) booklet so that you will have up to date 

information concerning your Pension Plan in one place. 

Statute of Limitations for Legal Action Against the Plan 

In order to receive benefits from the Pension Plan, you must file an application for benefits on a form provided by 

the Fund Office. If your application for benefits is denied – in whole or in part – you will be notified in writing and 

given the opportunity to file an appeal for a full and fair review of the benefit decision. The Plan’s “claims and 

appeals” provisions are described in pages 47-51 of your SPD and in Section 10.04 of the Pension Plan. 

Appeals must be filed within the timeframes described in the SPD and Plan. It is only after you have exhausted 

your appeal rights under the Plan that you may file a lawsuit under ERISA §502. 

Effective March 1, 2014, you may not file any legal action against the Pension Fund or the Board of Trustees of the 

Fund more than two years after your claim’s appeal has been denied by the Fund. However, you may file an appeal 

or take legal action beyond the two years if you later have information and evidence that was not available to you at 

the time of the Board of Trustees’ decision. 

Eligibility and Disability Changes 

As a result of the most recent Collective Bargaining Agreement, the way Hours and Contributions are credited by 

the Plan has been modified for owners, partners, shareholders, members of the board of directors of a corporation, 

officers of an individual employer, superintendents above the rank of foreman or general foreman, or any other 

individuals who are in any other way interested in the profits of an employer. Individuals in these positions are not 

eligible for Future Service Eligibility Credit for Non-Working Periods related to disabilities with “onset dates” for work 

performed on or after July 1, 2014. Furthermore, Hours reported for these Participants on or after July 1, 2014, will 

not be used to satisfy Disability Pension Eligibility requirements or to determine the amount of a Disability Pension. 

Future Service Eligibility Credit for Periods of Disability 

Effective January 1, 2015, changes are being made to how Disability Credit Hours are granted towards earning 

Future Service Eligibility Credit for periods during which you were not working in Covered Employment due to 

disability. 

In order to qualify for Disability Credit Hours, you must have at least seven (7) full Eligibility Credits (excluding any 

lost due to a Permanent Break in Service) based on Hours of Work in Northern California or hours granted for 

Qualified Military Service (under the Uniformed Services Employment and Reemployment Rights Act or 

“USERRA”).


Non-working periods eligible for Disability Credit Hours are: 

‣ Disability for a period in which California State Disability Insurance (SDI) benefits were paid or which 

constituted a valid waiting period for such benefits; or 

‣ Disability for a period for which Workers’ Compensation temporary disability benefits or temporary disability 

benefits under the Longshoremen’s and Harbor Workers’ Compensation Act were paid, or which 

constituted a valid waiting period for such benefits. 

Disability Credit Hours are provided at the rate of the lesser of: 

‣ 35 hours per week; or 

‣ The average number of hours worked by the Participant including hours granted for Qualified Military 

Service under the Uniformed Services Employment and Reemployment Rights Act (USERRA), during the 

24 full months preceding the period of disability or date of application – whichever produces the higher 

number. 

The maximum number of Disability Credit Hours is the greater of the following: 

‣ 20% of the total Hours of Work in Covered Employment and Hours in Qualified Military Service since your 

Contribution Date; or 

‣ Total Disability Hours credited for non-working periods as of January 1, 2015. 

In order to receive Disability Credit Hours, you must provide written notice and proof of disability within 12 months 

of the onset of disability. The Board of Trustees has sole discretion to determine the required proof of disability. 

Payment option name change from “Husband-and-Wife Pension” to “Joint and Survivor Pension” 

If you are married at Retirement, the Plan is designed to provide a lifetime income to you with a continuing income 

to your Spouse (in the event of your death) unless you and your spouse elect otherwise. The Plan’s default 

payment option, which for many years was called a “Husband-and-Wife Pension”, has now been renamed a “Joint 

and Survivor Pension”. This new wording does not affect the amount of any pension, or how it is calculated. It is 

simply a name change to make the Plan terminology consistent with recent court rulings and regulatory guidance. 

Questions 

If you have any questions concerning whether you are entitled to Disability Credit Hours or your Pension benefits in 

general, please contact the Trust Fund Office at: 

Carpenters Funds Administrative Office of Northern California, Inc. 

P.O. Box 2280 

Oakland, CA 94621-1418 

(510) 633-0333 

(888) 547-2054 (Toll-Free) 



This notice is a brief summary of specific Plan changes and is not intended to describe all aspects of the Plan 

relevant to your individual situation. More details are contained in your SPD booklet. However, your eligibility for 

benefits and the amount of those benefits can only be determined by consulting the Revised and Restated Pension 

Plan for the Carpenters Pension Trust Fund for Northern California.


CARPENTERS ANNUITY TRUST FUND 

FOR NORTHERN CALIFORNIA 



Tel. (510) 633-0333 (888) 547-2054 Fax (510) 633-0215 


October 30, 2014 

TO: 

FROM: 

RE: 

All Annuity Plan Participants 



Annuity Valuation Unitized Accounting 

At the May 2014 Carpenters Annuity Trust Fund for Northern California Board meeting, the 

Trustees authorized a significant change to the valuation process for Individual Accounts. The 

new process creates shares that will be valued daily. New shares will be allocated to individual 

accounts monthly as additions/contributions are allocated. The number of shares will be 

reduced as deductions/expenses are applied. The previous method of assessing quarterly noninvestment 

expenses and dividing those costs equally by the number of open accounts at the 

quarterly valuation date will continue. 

Effective with the quarter beginning December 1, 2014, Individual Accounts will be valued using 

a “unitized accounting” method similar to methods used by other retirement accounts. Under 

the new unitized accounting method, Participants will be issued shares in return for their 

Employer Contributions or other additions. Shares will be converted back into a dollar value 

when benefits are distributed. Investment gains, losses, and expenses are reflected in the 

share price, which is adjusted daily. An individual’s account balance will be equal to the number 

of shares owned, times the Trustee Directed Net Asset Value (NAV) per share. 

The NAV per share will be updated daily based on the most current available information for the 

various asset classes. Daily returns for some assets, such as real estate, private equity, and 

others are not available. For those assets, the most recent periodic market valuation will remain 

unchanged each day until the next periodic market value update for the asset occurs. Quarterly 

expenses that have not already been accounted for in the Daily Valuation process will continue 

to be assessed as a flat fee with all accounts paying the same amount, as part of the quarter 

end statement process. 

Under this method of valuing Individual Accounts, rather than waiting for the end of a quarter for 

new employer contributions to participate in market fluctuations, additional shares will be 

allocated to an individual’s account monthly if contributions are allocated. Money transferred to 

or from a Self Directed Account will still get earnings based on the Daily Valuation Factor, but 

the accounting will now be based on the day’s NAV per share. 

On or about November 30, 2014, each Participant’s Trustee Directed Account will be “unitized”, 

using an initial share price of $100. Setting the initial share price is just a starting place and will 

have no impact on the assets of the Fund or the amount in any Individual Account. After the 

initial conversion, the $100 share price will ebb and flow with periodic market returns. On the 

date of the conversion, the number of shares owned by a Participant will be the value of the 

Participant’s Trustee Directed Subaccount, divided by the share price of $100. For remainder 

amounts, partial shares will be credited.


The clarification contained herein is provided as a general guideline of the Annuity Fund’s 

“unitized accounting” method of valuing Individual Annuity accounts. This memorandum is only 

a brief summary intended to be used as a guideline, and does not supersede or replace any 

Plan documents. Please keep this notice with your benefit booklet. If you have any questions, 

please contact Benefit Services at the Fund Office at (510) 633-0333 or toll free at (888) 547- 

2054. You may also send an e-mail to benefitservices@carpenterfunds.com. Forms and 

information can be found on our website at www.carpenterfunds.com. 

The Board of Trustees maintains the right to change or discontinue the types and amounts of 

benefits under this Plan. This notice is intended as a summary only, and actual Plan documents 

will be used to interpret the Plan. Only the full Board of Trustees is authorized to interpret the 

Plan. The Board has discretion to decide all questions about the Plan, including questions about 

your eligibility for benefits and the amount of any benefits payable to you. No individual Trustee, 

Employer or Union Representative has authority to interpret this Plan on behalf of the Board or 

to act as an agent of the Board. 

In accordance with ERISA reporting requirements this document serves as your Summary of 

Material Modifications to the Plan.






(510) 633-0333 ▪ (888) 547-2054 


December 19, 2014 

TO: 

FROM: 

RE: 

All Participants, Beneficiaries, Participating Local Unions, and 

Contributing Employers 


CARPENTERS PENSION TRUST FUND FOR NORTHERN CALIFORNIA 

NOTICE OF CRITICAL STATUS 

Plan Year: September 1, 2014 – August 31, 2015 

If you are currently retired and receiving a monthly benefit payment from the Pension Fund, 

your monthly check will continue uninterrupted. 

The Pension Protection Act of 2006 (“PPA”) imposed rules designed to accelerate the funding of defined benefit 

plans like the Carpenters Pension Trust Fund for Northern California. Previously, plans were required to 

address funding issues only when a plan would not satisfy minimum funding standards for the current year, and 

could spread investment losses over longer periods of time. Alternatively, the PPA mandates that plans 

accelerate funding, anticipate future funding issues based upon projections, and for those certified to be in 

critical status to develop a “Rehabilitation Plan.” 

Federal law requires that you receive this notice. Following the determination of critical status (“red zone”) for 

prior Plan Years, a Rehabilitation Plan was adopted that was designed to have the Pension Plan emerge from 

the red zone within the time frame allowed by law. 

This is to inform you that on November 26, 2014 the actuary for the Carpenters Pension Trust Fund for Northern 

California (the “Plan”) certified to the U.S. Department of the Treasury and to the Board of Trustees, that the 

Plan remains in critical status (the “red zone”) for the Plan Year beginning September 1, 2014. The certification 

also notified the IRS that the Plan is making the scheduled progress in meeting the requirement of its 

Rehabilitation Plan. 

Although the Pension Plan remains in critical (red zone) status, because the Rehabilitation 

Plan continues to address long term funding issues, no new changes are required at this time. 

CRITICAL STATUS 

According to provisions of the PPA, for the Plan Year beginning September 1, 2014, the Plan is labeled as being 

in critical status because (1) the Plan has an accumulated funding deficiency for the current Plan Year, and (2) 

the Plan was in critical status last year and is projected to have an accumulated funding deficiency over the next 

eight Plan Years (2015-2022). 

REHABILITATION PLAN 

The Plan’s actuary certified the Plan was in critical status for the first time for the Plan Year beginning 

September 1, 2009. Federal law requires that pension plans in critical status adopt a Rehabilitation Plan aimed 

at restoring the financial health of the plan. This is the sixth year the Plan has been in critical status. The law 

permits pension plans in critical status to reduce, or even eliminate, benefits called “adjustable benefits” as part 

of a Rehabilitation Plan. On July 27, 2010, the Board of Trustees adopted a Rehabilitation Plan consisting of 

two contribution rate/benefit schedules. All contributing employers and bargaining units adopted the 

1


Rehabilitation Plan’s “Preferred Schedule” which does not require elimination or reduction in “adjustable 

benefits.” To minimize the impact to participants and employers, it was anticipated that the adopted 

Rehabilitation Plan would address the long term funding issues over the full time frame allowed by law. 

The Plan remains in critical status, however, modification to the Rehabilitation Plan has not been necessary and 

the Plan is continuing to make scheduled progress in meeting the requirements of its Rehabilitation Plan. 

If, in future years, the Trustees determine that future benefit reductions are necessary, you will receive a 

separate notice identifying and explaining the effect of those reductions. Any reduction of adjustable benefits 

(other than a repeal of a recent benefit increase) will not reduce the level of a participant’s basic benefit payable 

at Normal Retirement Age. 

Please be advised that whether or not the Plan reduces adjustable benefits in the future, the Plan has not been 

permitted to pay lump sum benefits (i.e., Level Income Option benefits) since it first provided Notice of Critical 

Status on December 23, 2009 and will not be permitted to do so while it continues to be in critical status. 

ADJUSTABLE BENEFITS 

During the rehabilitation period, the Plan continues to offer the following adjustable benefits: 

‣ Disability Pension Benefits (if not yet in pay status); 

‣ Service Pension Benefits; 

‣ Early Retirement Pension Subsidies; 

‣ 75% and 100% Husband-and-Wife Pension; 

‣ Pre-Retirement Death Benefit; 

‣ 36 and 60 month Guarantee connected with Single-Life Pension. 

If the existing Rehabilitation Plan has to be modified sometime in the future, adjustable benefits may be reduced 

or eliminated. 

EMPLOYER SURCHARGE 

The law requires that all contributing employers who have not agreed to a Collective Bargaining Agreement that 

implements the Rehabilitation Plan, pay to the Plan a surcharge to help correct the Plan's financial situation 

beginning 30 days after the employer is notified that the Plan is in critical status. If applicable, the surcharge 

would have been 5% of an employer’s negotiated contribution rate applicable the first Plan Year in critical status 

(September 1, 2009 through August 31, 2010) and would have been increased to 10% beginning September 1, 

2010 for each succeeding Plan year in which the Plan remains in critical status. All contributing employers 

have agreed to a Collective Bargaining Agreement implementing the Rehabilitation Plan, therefore no 

surcharges have been assessed. 

WHAT’S NEXT 

We understand that legally required notices like this one can create concern about the Plan’s future. Be 

assured that the Board of Trustees takes very seriously its obligation to preserve the financial viability 

of the Plan and has been very proactive in addressing funding issues. Also, if you are currently retired 

and receiving a monthly benefit payment from the Pension Fund, your monthly check will continue 

uninterrupted. 

With the assistance of the Plan’s actuary, legal counsel and other professionals, and working with the 

contributing employers and the Union, the Trustees have developed a Rehabilitation Plan that addresses these 

issues. As a final note, since the Pension Plan is influenced by economic and financial variables beyond our 

control (such as market volatility and changes in employment and/or the number of contributing employers), 

unexpected developments can further affect the Plan’s status and may require additional future corrective 

actions. Each year the Board of Trustees will review the Plan’s progress with its professional advisors and 

adjust Plan rules as necessary to maintain the Plan’s financial integrity. 

2


WHERE TO GET MORE INFORMATION 

For more information about this notice or the Pension Plan in general, please contact the Trust Fund Office at 

the address or phone number below. You have a right to receive a copy of the Rehabilitation Plan from the Plan. 


P.O. Box 2280 


Toll-Free: (888) 547-2054 or (510) 633-0333 


As required by law, this notice is being provided to the Pension Benefit Guaranty Corporation (PBGC) and the 

Department of Labor. 

3






(510) 633-0333 ▪ (888) 547-2054 



TO: 

FROM: 

RE: 

All Participants, Beneficiaries, Participating Local Unions, and 

Contributing Employers 


CARPENTERS PENSION TRUST FUND FOR NORTHERN CALIFORNIA 

ANNUAL FUNDING NOTICE 

Plan Year: September 1, 2013 – August 31, 2014 

Introduction 

This notice includes important funding information about your Pension Plan (“the Plan”). This notice also 

provides a summary of federal rules governing multiemployer plans in reorganization and insolvent plans and 

benefit payments guaranteed by the Pension Benefit Guaranty Corporation (PBGC), a federal agency. This 

notice is for the Plan Year beginning September 1, 2013, and ending August 31, 2014 (“Plan Year”). 

Funded Percentage 

The funded percentage of a plan is a measure of how well that plan is funded. This percentage is obtained by 

dividing the Plan’s assets by its liabilities on the valuation date for the plan year. In general, the higher the 

percentage, the better funded the plan. The Plan’s funded percentage for the Plan Year and two (2) preceding 

Plan Years is set forth in the chart below, along with a statement of the value of the Plan’s assets and liabilities 

for the same period. 

Valuation Date 

2013 Plan Year 

(as of) Sept. 1, 2013 


(as of) Sept. 1, 2012 


(as of ) Sept. 1, 2011 

Funded Percentage 68.28% 67.13% 68.36% 

Value of Assets $2,596,299,752 $2,425,401,209 $2,343,439,149 

Value of Liabilities $3,802,470,697 $3,613,178,352 $3,427,980,353 

Fair Market Value of Assets 

Asset values in the chart above are actuarial values, not market values. Market values tend to show a clearer 

picture of a plan’s funded status as of a given point in time. However, because market values can fluctuate daily 

based on factors in the marketplace, such as changes in the stock market, pension law allows plans to use 

actuarial values for funding purposes. While actuarial values fluctuate less than market values, they are 

estimates. As of August 31, 2014, the fair market value of assets was $2,809,499,830 (unaudited number, 

subject to change). As of August 31, 2013, the fair market value of the Plan’s assets was $2,473,679,528. As of 

August 31, 2012, the fair market value of the Plan’s assets was $2,204,431,702. 

Participant Information 

The total number of participants in the Plan as of the Plan’s valuation date was 44,538. Of this number, 19,492 

were active participants and beneficiaries, 14,490 were retired or separated from service and receiving benefits, 

and 10,556 were retired or separated from service and entitled to future benefits. 

1


Funding & Investment Policies 

The law requires that every pension plan have a procedure for establishing a funding policy to carry out the plan 

objectives. A funding policy relates to the level of contributions needed to pay for benefits promised under the 

plan currently and over the years. For this Plan, the collective bargaining agreements provide for employer 

contributions on an agreed-upon cents-per-hour basis. There are no employee contributions. 

Once money is contributed to the Plan, the money is invested by Plan officials called fiduciaries. Specific 

investments are made in accordance with the Plan’s investment policy. Generally, an investment policy is a 

written statement that provides the fiduciaries that are responsible for plan investments with guidelines or 

general instructions concerning various types or categories of investment management decisions. The 

investment policy of the Plan is to invest in a manner consistent with the fiduciary standards of ERISA, namely 

(1) to undertake all transactions in the sole interest of Plan Participants and Beneficiaries, (2) to provide benefits 

and defray reasonable expenses of Plan administration in a prudent manner, and (3) to diversify assets. All 

investments shall be made in compliance with relevant laws and the Trust Agreement governing the Trust. 

In accordance with the Plan’s investment policy, the Plan’s assets were allocated among the following 

categories of investments as of the end of the Plan Year. The following allocations are percentages of total 

assets as of August 31, 2014: 

Allocation of Investments – Year End August 31, 2014 

Interest-bearing cash 0.00% 

U.S. Government Securities 3.65% 

Corporate Debt Instruments 

Preferred 

0.00% 

All Others 

9.84% 

Corporate Stocks 

Preferred 

0.00% 

Common 

28.94% 

Partnership/Joint Venture Interests 11.41% 

Real Estate 0.64% 

Loans 0.57% 

Value of Interest in Common/Collective Trusts 19.81% 

Value of Interest in Pooled Separate Accounts 1.90% 

Value of Interest in 103-12 Investment Entities 4.72% 

Other 18.52% 

TOTAL 100.00% 

For information about the Plan’s investment in any of the following types of investments as described in the 

chart above – common/collective trusts, pooled separate accounts, master trust investment accounts, or 103-12 

investment entities – contact the Plan Administrator at the address provided under “Where to Get More 

Information.” 

Critical or Endangered Status 

Under federal pension law a plan generally will be considered to be in “endangered” or “seriously endangered” 

status if, at the beginning of the plan year, the funded percentage of the plan is less than 80 percent or in 

“critical” status if the percentage is less than 65 percent (other factors may also apply). If a pension plan enters 

endangered status, the trustees of the plan are required to adopt a funding improvement plan. Similarly, if a 

pension plan enters critical status, the trustees of the plan are required to adopt a rehabilitation plan. 

Rehabilitation and funding improvement plans establish steps and benchmarks for pension plans to improve 

their funding status over a specified period of time. 

On November 25, 2009, for the Plan Year beginning September 1, 2009, the Plan’s actuary certified the Plan to 

be in critical status for the first time because, a funding deficiency was projected in four years, the Plan’s liability 

for inactive participants was greater than that for active participants, and the sum of the Plan's normal cost and 

interest on the unfunded benefits for the current year exceeded the present value of all expected contributions 

for the year. The Plan has continued to be certified to be in critical status for the Plan Years beginning 

2


September 1, 2010, September 1, 2011, September 1, 2012, as well as the September 1, 2013 Plan Year 

described in this Notice. 

On December 23, 2009, all Participants, Beneficiaries, participating Local Unions, and the Pension Benefit 

Guaranty Corporation were notified of the Plan’s critical status, the requirement that the Board of Trustees adopt 

a rehabilitation plan, and the possibility that certain types of adjustable benefits could be eliminated under the 

rehabilitation plan. 

On May 26, 2010, as permitted under the Worker, Retiree, and Employer Recovery Act of 2008 (WRERA), the 

Board of Trustees elected to extend the Plan’s 10 year rehabilitation period to 13 years. 

On July 27, 2010, as required by Federal law for pension plans in critical status, a Rehabilitation Plan consisting 

of two contribution rate/benefit schedules aimed at restoring the financial health of the Plan was adopted by the 

Board of Trustees. All contributing employers and bargaining units adopted the Rehabilitation Plan’s “Preferred 

Schedule” which provided for a series of employer contribution increases and reductions in the future benefit 

accrual formula. However, no previously earned benefits or “adjustable benefits” were reduced or eliminated. 

The Plan is continuing to make scheduled progress in meeting the requirement of its Rehabilitation Plan. 

You may obtain a copy of the Plan’s Rehabilitation Plan and the actuarial and financial data that demonstrate 

any action taken by the Plan toward fiscal improvement by contacting the Plan Administrator at the address 

provided under “Where to Get More Information.” 

Events with Material Effect on Assets or Liabilities 

Federal law requires Trustees to provide in this notice a written explanation of events, taking effect in the current 

Plan year, which are expected to have a material effect on plan liabilities or assets. There are no scheduled 

Plan Amendments or known events that are to take effect during the Plan year beginning September 1, 2014 

and ending August 31, 2015, that would have a material effect on Plan liabilities and assets for the year. 

Right to Request a Copy of the Annual Report 

A pension plan is required to file with the US Department of Labor an annual report (i.e., Form 5500) containing 

financial and other information about the plan. Copies of the annual report are available from the US 

Department of Labor, Employee Benefits Security Administration’s Public Disclosure Room at 200 Constitution 

Avenue, NW, Room N-1513, Washington, DC 20210, or by calling (202) 693-8673. You may obtain a copy of 

the Plan’s Annual Report by making a written request to the Plan Administrator. A copy of the Annual Report will 

not be available until June 2015. 

Summary of Rules Governing Plans in Reorganization and Insolvent Plans 

Federal law has a number of special rules that apply to financially troubled multiemployer plans. Under so-called 

“plan reorganization rules,” a plan with adverse financial experience may need to increase required contributions 

and may, under certain circumstances, reduce benefits that are not eligible for the PBGC’s guarantee 

(generally, benefits that have been in effect for less than 60 months). If a plan is in reorganization status, it must 

provide notification that the plan is in reorganization status and that, if contributions are not increased, accrued 

benefits under the plan may be reduced or an excise tax may be imposed (or both). The law requires the plan to 

furnish this notification to each contributing employer and the labor organization. 

Despite the special plan reorganization rules, a plan in reorganization nevertheless could become insolvent. A 

plan is insolvent for a plan year if its available financial resources are not sufficient to pay benefits when due for 

the plan year. An insolvent plan must reduce benefit payments to the highest level that can be paid from the 

plan’s available financial resources. If such resources are not enough to pay benefits at a level specified by law 

(see Benefit Payments Guaranteed by the PBGC, below), the plan must apply to the PBGC for financial 

assistance. The PBGC, by law, will loan the plan the amount necessary to pay benefits at the guaranteed level. 

Reduced benefits may be restored if the plan’s financial condition improves. 

A plan that becomes insolvent must provide prompt notification of the insolvency to participants and 

beneficiaries, contributing employers, labor unions representing participants, and the PBGC. In addition, 

participants and beneficiaries also must receive information regarding whether, and how, their benefits will be 

3


reduced or affected as a result of the insolvency, including loss of a lump sum option. This information will be 

provided for each year the plan is insolvent. 

Benefit Payments Guaranteed by the PBGC 

The maximum benefit that the PBGC guarantees is set by law. Only vested benefits are guaranteed. 

Specifically, the PBGC guarantees a monthly benefit payment equal to 100 percent of the first $11 of the Plan’s 

monthly benefit accrual rate, plus 75 percent of the next $33 of the accrual rate, times each year of credited 

service. The PBGC’s maximum guarantee, therefore, is $35.75 per month times a participant’s years of credited 

service. 

Example 1: If a participant with 10 years of credited service has an accrued monthly benefit of $500, the accrual 

rate for purposes of determining the PBGC guarantee would be determined by dividing the monthly benefit by 

the participant’s years of service ($500/10), which equals $50. The guaranteed amount for a $50 monthly 

accrual rate is equal to the sum of $11 plus $24.75 (.75 x $33), or $35.75. Thus, the participant’s guaranteed 

monthly benefit is $357.50 ($35.75 x 10). 

Example 2: If the participant in Example 1 has an accrued monthly benefit of $200, the accrual rate for purposes 

of determining the guarantee would be $20 (or $200/10). The guaranteed amount for a $20 monthly accrual rate 

is equal to the sum of $11 plus $6.75 (.75 x $9), or $17.75. Thus, the participant’s guaranteed monthly benefit 

would be $177.50 ($17.75 x 10). 

The PBGC guarantees pension benefits payable at normal retirement age and some early retirement benefits. 

In calculating a person’s monthly payment, the PBGC will disregard any benefit increases that were made under 

the plan within 60 months before the earlier of the plan’s termination or insolvency (or benefits that were in effect 

for less than 60 months at the time of termination or insolvency). Similarly, the PBGC does not guarantee preretirement 

death benefits to a spouse or beneficiary (e.g., a qualified pre-retirement survivor annuity) if the 

participant dies after the plan terminates, benefits above the normal retirement benefit, disability benefits not in 

pay status, or non-pension benefits, such as health insurance, life insurance, death benefits, vacation pay, or 

severance pay. 

Where to Get More Information 

For more information about this notice, or the Pension Plan in general, please contact the Trust Fund Office at: 


P.O. Box 2280 


Toll-Free: (888) 547-2054 or (510) 633-0333 


For identification purposes, the official Plan number is 001 and the Plan’s employer identification number or 

“EIN” is 94-6050970. For more information about the PBGC and benefit guarantees, go to the PBGC's website, 

www.pbgc.gov, or call PBGC toll-free at 1(800) 400-7242 (TTY/TDD users may call the Federal Relay Service 

toll free at 1(800) 877-8339 and ask to be connected to 1(800) 400-7242). 

4







Tel. (510) 633-0333 (888) 547-2054 Fax (510) 633-0215 


TO: 

FROM: 

RE: 

All Active Plan A, B, R, and Flat Rate Participants and their Dependents, including 

COBRA Beneficiaries 



BENEFIT CHANGES 

Sole Pharmacy to Dispense Certain Medications and/or Sole Medical Provider or 

Facility to Receive Medical Services 

Stakeholder Eligibility 

Qualifying for Retiree Health and Welfare 

The Board of Trustees of the Carpenters Health and Welfare Trust Fund for California modified the Plan 

Rules and Regulations for Active Participants and Dependents as follows: 

To protect your benefit dollars, the Trustees continue to implement a variety of fraud, waste, and abuse 

procedures and practices. Evidence shows that in this country hundreds of billions of medical dollars are 

wasted each year through fraud and waste, and that much can be done to avoid falling victim to the 

abuse. To help avoid payment for inappropriate services and/or prescription drugs, the Trustees have 

hired professionals to look for abuse, and have modified the Plan to help manage the risk. If a case of 

provider or patient abuse is identified, a patient may be limited to a single medical or prescription 

provider. In such cases, when through the investigation or appeals process the matter is resolved, such 

limitations may be lifted. 

‣ EFFECTIVE JUNE 1, 2014: 

Sole pharmacy to dispense certain medications and/or sole medical provider or facility to 

receive certain medical services: The Fund may require you to fill certain prescription drugs at a 

specific pharmacy or to receive medical services from a single medical provider and/or medical 

facility. You will be notified in writing if you need to fill a prescription at a specific pharmacy or if you 

are required to use a specific provider or medical facility. After you have been notified, if you choose 

to continue to get the medication from any pharmacy other than the one that has been specified, or to 

receive medical services from a provider other than the one that has been specified, no benefits will 

be available for the unspecified pharmacy or medical provider. 

‣ EFFECTIVE JULY 1, 2014: 

Stakeholder Eligibility: A “Stakeholder” is an owner, partner, shareholder, member of the board of 

directors of a corporation, officer of an individual employer, superintendent above the rank of foreman 

or general foreman, or other individual who is in any other way interested in the profits of the 

employer – other than hourly wages pursuant to a collective bargaining agreement. 

A Stakeholder will be eligible for coverage under the Fund only if all contributions due on behalf of all 

hours for all employees are current and all delinquencies are resolved. A Stakeholder must work an 

average of 145 hours during the three most current work months and those hours must be reported to 

the Fund. 

Coverage for a Stakeholder will terminate on the earlier of the following dates: 

 

If performing work covered under a collective bargaining agreement, eligibility will end on the 

first day of the second calendar month which follows a period of not more than three 

consecutive calendar months during which she/he averaged less than 145 work hours per 

month.


 

 

The first day of the month following the employer’s failure to resolve delinquencies or remit all 

contributions due on behalf of all hours reported for all employees. 

If following a period of having hours reported by an individual employer as a Stakeholder, the 

employer stops reporting hours for such individual, the first day of the second calendar month. 

An Hour Bank for a Stakeholder will be cancelled on the earlier of the following dates: 

 

 

If performing work covered under a collective bargaining agreement, the first day of the second 

calendar month which follows a period of not more than three consecutive calendar months 

during which she/he averaged less than 145 work hours per month. 

If following a period when previously reported as a Stakeholder, the employer stops reporting 

hours for such individual who remains in the employ of the employer in any capacity, the first 

day of the second calendar month. 

Please note: A Stakeholder is not eligible for Disability Extension benefits, Supplemental Weekly 

Disability benefits or COBRA Continuation coverage. 

‣ EFFECTIVE JANUARY 1, 2015, the Board of Trustees will modify the Plan Rules and Regulations 

for Retirees. 

Qualifying for Retiree Health and Welfare: A person meeting all the requirements at the time of 

retirement may qualify for Retiree Health and Welfare benefits. One of those criteria is having a 

minimum number of Eligibility Credits in the Carpenters Pension Trust Fund for Northern California or 

related plan at the time of retirement. For Retirements effective on or after January 1, 2015, a 

person must have ten full Eligibility Credits, based on Hours of Work or Hours of Qualified 

Military Service, in order to meet the ten year service requirement. 

Grandfathered Health Plan: The Board of Trustees of the Carpenters Health and Welfare Trust Fund 

for California believes these plans are “grandfathered health plans” under the Patient Protection and 

Affordable Care Act (“the Affordable Care Act”). As permitted by the Affordable Care Act, a 

grandfathered health plan can preserve certain basic health coverage that was already in effect when 

that law was enacted. Being a grandfathered health plan means that your plan may not include certain 

consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement 

for the provision of preventative health services without any cost sharing. However, grandfathered health 

plans must comply with certain other consumer protections in the Affordable Care Act, for example the 

elimination of lifetime limits on benefits. Questions regarding which protections apply and which 

protections do not apply to a grandfathered health plan and what might cause a plan to change from 

grandfathered health plan status can be directed to the Plan Administrator or the Department of Labor at 

1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which 

protections do and do not apply to grandfathered health plans. 

Please keep this notice with your benefit booklet. If you have any questions, please contact Benefit 

Services at the Fund Office at (510) 633-0333 or toll free at (888) 547-2054. You may also send an email 

to benefitservices@carpenterfunds.com. Forms and information can be found on our website at 


The Board of Trustees maintains the right to change or discontinue the types and amounts of benefits 

under this Plan. This notice is intended as a summary only, and actual Plan documents will be used to 

interpret the Plan. Only the full Board of Trustees is authorized to interpret the Plan. The Board has 

discretion to decide all questions about the Plan, including questions about your eligibility for benefits and 

the amount of any benefits payable to you. No individual Trustee, Employer or Union Representative has 

authority to interpret this Plan on behalf of the Board or to act as an agent of the Board. 

In accordance with ERISA reporting requirements this document serves as your Summary of Material Modifications 

to the Plan. 

2


January 9, 2015 





(510) 633-0333 ▪ (888) 547-2054 


NOTICE TO INTERESTED PARTIES 

1. Notice To: All present employees covered by a collective bargaining agreement or 

participation agreement pursuant to which the Carpenters Pension Trust Fund for 

Northern California is maintained. 

An application is to be made to the Internal Revenue Service for an advance 

determination on the qualification of the following employee pension benefit plan: 

2. Name of Plan: Carpenters Pension Trust Fund for Northern California 

3. Plan Identification Number: 001 

4. Name and Address of Applicant: Board of Trustees, Carpenters Pension Trust Fund 

for Northern California, 265 Hegenberger Road, Oakland, CA 94621 

5. Applicant ID Number: 94-6050970 

6. Name and Address of Plan Administrator: Board of Trustees, Carpenters Pension 

Trust Fund for Northern California, 265 Hegenberger Road, Oakland, CA 94621 

7. The application will be filed on JANUARY 20, 2015 for an advance determination as to 

whether the plan meets the qualification requirements of § 401 (a) of the Internal 

Revenue Code of 1986, with respect to the plan’s amendment. The application will be 

filed with: 

EP Determinations 

Internal Revenue Service 

P.O. Box 12192 

Covington, KY 41012-0192 

8. The employees eligible to participate under the plan are employees covered by a 

collective bargaining agreement or participation agreement and on whose behalf 

contributions are required to the Plan pursuant to such agreement. 

9. The Internal Revenue Service has previously issued a determination letter with respect 

to the qualification of this plan. 

RIGHTS OF INTERESTED PARTIES 

10. You have the right to submit to EP Determinations, at the above address, either 

individually or jointly with other interested parties, your comments as to whether this plan 

meets the qualification requirements of the Internal Revenue Code. 

You may instead, individually or jointly with other interested parties, request the 

Department of Labor to submit, on your behalf, comments to EP Determinations 

regarding qualification of the plan. If the Department declines to comment on all or some 

of the matters you raise, you may, individually, or jointly if your request was made to the


Department jointly, submit your comments on these matters directly to EP 

Determinations. 

REQUESTS FOR COMMENTS BY THE DEPARTMENT OF LABOR 

11. The Department of Labor may not comment on behalf of interested parties unless 

requested to do so by the lessor of 10 employees or 10 percent of the employees who 

qualify as interested parties. The number of persons needed for the Department to 

comment with respect to this plan is 10. If you request the Department to comment, your 

request must be in writing and must specify the matters upon which comments are 

requested, and must also include: 

(1) the information contained in items 2 through 5 of this Notice; and 

(2) the number of persons needed for the Department to comment. 

A request to the Department to comment should be addressed as follows: 

Deputy Assistant Secretary 


ATTN: 3001 Comment Request 


200 Constitution Avenue, N.W. 


COMMENTS TO THE INTERNAL REVENUE SERVICE 

12. Comments submitted by you to EP Determinations must be in writing and received by 

them by MARCH 6, 2015. However, if there are matters that you request the 

Department of Labor to comment upon on your behalf, and the Department declines, 

you may submit comments on these matters to EP Determinations to be received by 

them within 15 days from the time the Department notifies you that it will not comment 

on a particular matter, or by MARCH 6, 2015, whichever is later, but not after MARCH 

21, 2015. A request to the Department to comment on your behalf must be received by 

it by February 4, 2015 if you wish to preserve your right to comment on a matter upon 

which the Department declines to comment, or by FEBRUARY 14, 2015 if you wish to 

waive that right. 

ADDITIONAL INFORMATION 

13. Detailed instructions regarding the requirements for notification of interested parties may 

be found in sections 17 and 18 of Rev. Proc. 2013-6. Additional information concerning 

this application (including, where applicable, an updated copy of the plan and related 

trust; the application for determination; any additional documents dealing with the 

application that have been submitted to the Service; and copies of section 17 of Rev. 

Proc. 2013-6 are available Monday through Friday at 265 Hegenberger Road, Oakland, 

CA 94621 for inspection and copying. (There is a nominal charge for copying and/or 

mailing.) 

Page 2 of 2







(510) 633-0333 ▪ (888) 547-2054 



1. Notice To: All present employees covered by a collective bargaining agreement or 

participation agreement pursuant to which the Carpenters Annuity Trust Fund for 

Northern California is maintained. 

An application is to be made to the Internal Revenue Service for an advance 

determination on the qualification of the following employee pension benefit plan: 

2. Name of Plan: Carpenters Annuity Trust Fund for Northern California 


4. Name and Address of Applicant: Board of Trustees, Carpenters Annuity Trust Fund 

for Northern California, 265 Hegenberger Road, Oakland, CA 94621 


6. Name and Address of Plan Administrator: Board of Trustees, Carpenters Annuity 

Trust Fund for Northern California, 265 Hegenberger Road, Oakland, CA 94621 

7. The application will be filed on JANUARY 20, 2015 for an advance determination as to 

whether the plan meets the qualification requirements of § 401 (a) of the Internal 

Revenue Code of 1986, with respect to the plan’s amendment. The application will be 

filed with: 



P.O. Box 12192 


8. The employees eligible to participate under the plan are employees covered by a 

collective bargaining agreement or participation agreement and on whose behalf 

contributions are required to the Plan pursuant to such agreement. 

9. The Internal Revenue Service has previously issued a determination letter with respect 

to the qualification of this plan. 


10. You have the right to submit to EP Determinations, at the above address, either 

individually or jointly with other interested parties, your comments as to whether this plan 

meets the qualification requirements of the Internal Revenue Code. 

You may instead, individually or jointly with other interested parties, request the 

Department of Labor to submit, on your behalf, comments to EP Determinations 

regarding qualification of the plan. If the Department declines to comment on all or some 

of the matters you raise, you may, individually, or jointly if your request was made to the


Department jointly, submit your comments on these matters directly to EP 

Determinations. 


11. The Department of Labor may not comment on behalf of interested parties unless 

requested to do so by the lessor of 10 employees or 10 percent of the employees who 

qualify as interested parties. The number of persons needed for the Department to 

comment with respect to this plan is 10. If you request the Department to comment, your 

request must be in writing and must specify the matters upon which comments are 

requested, and must also include: 











12. Comments submitted by you to EP Determinations must be in writing and received by 

them by MARCH 6, 2015. However, if there are matters that you request the 

Department of Labor to comment upon on your behalf, and the Department declines, 

you may submit comments on these matters to EP Determinations to be received by 

them within 15 days from the time the Department notifies you that it will not comment 

on a particular matter, or by MARCH 6, 2015, whichever is later, but not after MARCH 

21, 2015. A request to the Department to comment on your behalf must be received by 

it by February 4, 2015 if you wish to preserve your right to comment on a matter upon 

which the Department declines to comment, or by FEBRUARY 14, 2015 if you wish to 

waive that right. 


13. Detailed instructions regarding the requirements for notification of interested parties may 

be found in sections 17 and 18 of Rev. Proc. 2013-6. Additional information concerning 

this application (including, where applicable, an updated copy of the plan and related 

trust; the application for determination; any additional documents dealing with the 

application that have been submitted to the Service; and copies of section 17 of Rev. 

Proc. 2013-6 are available Monday through Friday at 265 Hegenberger Road, Oakland, 

CA 94621 for inspection and copying. (There is a nominal charge for copying and/or 

mailing.) 

Page 2 of 2







(510) 633-0333 ▪ (888) 547-2054 



1. Notice To: All present employees covered by a collective bargaining agreement or participation 

agreement pursuant to which the Northern California Carpenters 401K Plan is maintained. 

An application is to be made to the Internal Revenue Service for an advance determination on the 

qualification of the following employee pension benefit plan: 

2. Name of Plan: Northern California Carpenters 401(k) Plan 


4. Name and Address of Applicant: Board of Trustees, Northern California Carpenters 401K Plan, 

265 Hegenberger Road, Oakland, CA 94621 


6. Name and Address of Plan Administrator: Board of Trustees, Northern California Carpenters 

401K Plan, 265 Hegenberger Road, Oakland, CA 94621 

7. The application will be filed on JANUARY 20, 2015 for an advance determination as to whether 

the plan meets the qualification requirements of § 401 (a) of the Internal Revenue Code of 1986, 

with respect to the plan’s amendment. The application will be filed with: 



P.O. Box 12192 


8. The employees eligible to participate under the plan are employees covered by a collective 

bargaining agreement or participation agreement and on whose behalf contributions are required 

to the Plan pursuant to such agreement. 

9. The Internal Revenue Service has previously issued a determination letter with respect to the 

qualification of this plan. 


10. You have the right to submit to EP Determinations, at the above address, either individually or 

jointly with other interested parties, your comments as to whether this plan meets the qualification 

requirements of the Internal Revenue Code. 

You may instead, individually or jointly with other interested parties, request the Department of 

Labor to submit, on your behalf, comments to EP Determinations regarding qualification of the 

plan. If the Department declines to comment on all or some of the matters you raise, you may, 

individually, or jointly if your request was made to the Department jointly, submit your comments 

on these matters directly to EP Determinations.



11. The Department of Labor may not comment on behalf of interested parties unless requested to 

do so by the lessor of 10 employees or 10 percent of the employees who qualify as interested 

parties. The number of persons needed for the Department to comment with respect to this plan 

is 10. If you request the Department to comment, your request must be in writing and must 

specify the matters upon which comments are requested, and must also include: 











12. Comments submitted by you to EP Determinations must be in writing and received by them by 

MARCH 6, 2015. However, if there are matters that you request the Department of Labor to 

comment upon on your behalf, and the Department declines, you may submit comments on these 

matters to EP Determinations to be received by them within 15 days from the time the 

Department notifies you that it will not comment on a particular matter, or by MARCH 6, 2015, 

whichever is later, but not after MARCH 21, 2015. A request to the Department to comment on 

your behalf must be received by it by February 4, 2015 if you wish to preserve your right to 

comment on a matter upon which the Department declines to comment, or by FEBRUARY 14, 

2015 if you wish to waive that right. 


13. Detailed instructions regarding the requirements for notification of interested parties may be found 

in sections 17 and 18 of Rev. Proc. 2013-6. Additional information concerning this application 

(including, where applicable, an updated copy of the plan and related trust; the application for 

determination; any additional documents dealing with the application that have been submitted to 

the Service; and copies of section 17 of Rev. Proc. 2013-6 are available Monday through Friday 

at 265 Hegenberger Road, Oakland, CA 94621 for inspection and copying. (There is a nominal 

charge for copying and/or mailing.)

Value Based Purchasing Design designated hospitals 


Hospitals 

highlighted have 

joined the California 

Joint Replacement Registry 

(CJRR) supported by PBGH. 

The registry is designed to 

collect and share data to provide 

credible feedback to orthopedic 

surgeons, hospitals and patients 

about their treatment decisions, quality 

of care, and patient outcomes. CalPERS 

recognizes these hospitals and surgeons 

for their commitment to the long term goal of 

improving treatment decisions and care delivery 

for patients receiving joint replacements. 

Adventist Medical Center 

Alvarado Hospital LLC 

Arroyo Grande Community Hospital 

Bakersfield Memorial Hospital 

Barton Memorial Hospital 

Cedars-Sinai Medical Center 

Community Hospital of the Monterey Peninsula 

Dameron Hospital 

Desert Regional Medical Center 

Eisenhower Medical Center 

El Camino Hospital 

Enloe Medical Center Inc 

French Hospital Medical Center 

Fresno Surgical Hospital 

Good Samaritan Hospital – San Jose 

Good Samaritan Hospital – Los Angeles 

Healdsburg District Hospital 

Hoag Orthopedic Institute 

Huntington Memorial Hospital 

John F Kennedy Memorial Hospital 

John Muir Medical Center - Concord Campus 

John Muir Medical Center - Walnut Creek Campus 

Kaweah Delta Medical Center 

Loma Linda University Medical Center 

Long Beach Memorial Medical Center 

Mercy Medical Center – Redding 

Methodist Hospital Of Sacramento 

Natividad Medical Center 

O’Connor Hospital 

Placentia Linda Hospital 

Queen of the Valley Medical Center 

San Antonio Community Hospital 

San Joaquin Community Hospital 

Santa Monica UCLA Medical Center 

Santa Rosa Memorial Hospital 

Sierra Vista Regional Medical Center 

Sonora Regional Medical Center 

St Agnes Medical Center 

St John’s Hospital And Health Center 

St Joseph Hospital – Orange 

St Jude Medical Center 

St Marys Medical Center 

St Vincent Medical Center 

Stanford University Hospital 

Stanislaus Surgical Hospital 

Thousand Oaks Surgical Hospital 

Torrance Memorial Medical Center 

Twin Cities Community Hospital Inc 

UC Davis Medical Center 

UCSD Medical Center 

UCSF Medical Center 

Valley Presbyterian Hospital 

ValleyCare Medical Center 

Hospitals highlighted in green are in the process of joining the CJRR. 

For more information about the CJRR, please visit caljrr.org.


AMENDMENT NO. 44 

to the 


Rules and Regulations 

For Plan A and Plan R Active Participants 

as restated January 1, 201 0 

A. Effective for disabilities that began on and after March 1, 2009, the following changes are made to 

the Disability Extension in Article 2: 

1. Subsections (2) of Section 2.0 l.g. and 2.02.e. for Plans A and R, respectively, are restated as 

follows: 

(2) To qualify for the Disability Extension, the Disabled Participant must file an application 

with the Fund within 1 year of the onset of Disability. 

~ 

Executed this _____:;:____ day of----"-~-~-=:-+-'~:::.....=:..::==---=------- , 20 1 0. 


of the 


5084671 v 1/00573.001 

Amendment 44, Plan AIR



to the 




as restated January 1, 2010 

Effective January 1, 2010, the following changes are made to the Plan: 

1. Section 2.01. Eligibility Rules for Active Participants - Plan A is amended by adding a new 

Subsection 2.0 1.h.( 4) as follows: 

(4) Effective January 1, 2010, a Participant who has not separated from service but has 

begun a mandatory commencement of Pension payments from the Carpenters Pension 

Trust Fund for Northern California by virtue of having reached the Required Beginning 

Date may maintain eligibility as an Active Employee under this Plan in accordance with 

Subsections 2.0 1.a. through e. 

2. Section 2.02. Eligibility Rules for Active Participants - Plan R is amended by adding a new 

Subsection 2.02.f.(4) as follows: 

(4) Effective January 1, 2010, a Participant who has not separated from service but has 

begun a tnandatory commencement of Pension payments from the Carpenters Pension 

Trust Fund for Northern California by virtue of having reached the Required Beginning 

Date may maintain eligibility as an Active Employee under this Plan in accordance with 

Subsections 2.02.a through c. 


of the 


Amendment 45, Plan NR



to the 

Carpenters Health and Welfare Ttust Fund for California 



as restated January 1 , 2 0 1 0 

A. Effective August 1, 201 0, all references to "PacifiCare Behavioral Health" in the Rules and 

Regulations are changed to "United Behavioral Health." 

B. Effective March 1, 2011, the following exclusion is added to Section 5. 05 to reflect the mandatory 

use of the mail order program after the second retail purchase of a long-term n1aintenance 

n1edication: 

r. The third purchase of a long-term maintenance Drug fron1 a retail pharmacy. After the second 

purchase of long-term maintenance Drug at a retail pharmacy, the Dtug must be purchased 

from the Pharmacy Benefit Manager's tnail order phannacy. 

C. Effective September 1, 2011 the following changes are made to the Plan: 

1. Section 1.13 is restated as follows: 

Section 1.13. The term "Dependent" means: 

a. The Participant's lawful spouse or qualified Domestic Partner. 

b. A child who is: 

(1) the Participant's natural child, stepchild or legally adopted child, or a child of the 

Participant required to be covered under a Qualified Medical Child Support Order, who 

is younger than 26 years of age, whether married or unmanied. Adopted children are 

eligible under the Plan when they are placed for adoption. Adult children between the 

ages of 19 and 26 who are not offered another employer-sponsored health plan through 

his or her own employer, d01nestic partner's employer, or spouse's employer, are 

eligible for Plan years beginning prior to January 1, 2014. 

Adult children between the ages of 19 and 26 who have access to another etnployer 

sponsored health plan, whether elected or not, other than a group health plan of a 

parent of the child, are not eligible under this provision. 

An adult child's eligibility will begin the first of the month following the date the 

Patiicipant enrolls the Dependent on a form approved by the Board of Trustees, if the 

Dependent is otherwise eligible. 

(2) an unmarried child for whom the Participant has been appointed legal guardian, 

provided the child is younger than 19 years of age and is considered the Participant's 

dependent for federal income tax purposes; 

Amendment No. 46, Plan AIR


(3) an unmarried child of the Participant's qualified Domestic Partner, provided the child 

is younger than 19 years of age and is pritnarily dependent on the Pmiicipant for 

financial suppmi; 

( 4) an unmanied child eligible under paragraph (2) or (3) above other than age who is 19 

but less than 23 years of age and a full tin1e student at an accredited educational 

institution, provided the child otherwise meets the require1nents of paragraph (2) or (3) 

above. Temporary absence from the Participant's place of abode due to education is 

not treated as absence for purposes of satisfying the residence requiren1ent of 

paragraphs (2) and (3) of this Subsection; 

( 5) an umnanied child not eligible under paragraph (1) above by virtue of having been 

offered other coverage, who is 19 but less than 23 years of age and a full tin1e student 

at an accredited educational institution and otherwise meets the require1nents of 

paragraph ( 1) above; or 

(6) an unmanied child of the Pmiicipant (or the Participant's spouse or qualified Domestic 

Partner) of any age who is prevented from earning a living because of 1nental or 

physical handicap, provided the child was disabled and eligible as a Dependent under 

this Plan before reaching age 19, or the Limiting Age described in paragraph (4) or (5) 

above, and provided the child is primarily dependent on the Participant for financial 

support. 

c. In accordance with ERISA Section 609(a), this Plan will provide coverage for a child of a 

Patiicipant if required by a Qualified Medical Child Support Order, including a National 

Medical Suppmi Order. A Qualified Medical Child Support Order or National Medical 

Support Order will supersede any requiretnents in the Plan's definition of Dependent stated 

above. 

2. Section 2.01.h is restated as follows: 

h. Special Conditions for Retired En1ployees Who Engage in Active Employment During the 

Period June 1, 2009 through December 31, 2013. 

(1) A Pmiicipant who is receiving benefit payments from the Carpenters Pension Trust 

Fund for Northern Califmnia, who engages in a type of work during the period of June 

1, 2009 through December 31, 2013 that requires contributions to this Fund but does not 

result in the suspension of benefit payments from the Carpenters Pension Trust Fund for 

Northetn California will not establish eligibility under this Plan. However, if the Retired 

Employee works enough consecutive hours that, in the absence of this rule, he/she 

would normally qualify for eligibility as an active Employee, 50% of the health and 

welfare contributions retnitted to this Plan on the Retired Employee's behalf will be 

used to offset his/her self-pay contributions for Retiree health coverage. Such offset will 

only be granted for 50% of contributions on up to a maxin1un1 of 480 hours in a 

calendar year. 

(2) If the individual is not an eligible Retired En1ployee in the Retiree Health and Welfare 

Plan, or if the hours worked are less than the number required to earn eligibility under 

this Plan in the absence of this rule, no health and welfare contributions will be credited 

on the individual's behalf. 

Amendment No. 46, Plan AIR 2


(3) A Retiree in the Carpenters Pension Trust Fund for Nmihetn California who has his or 

her pension suspended n1ay establish and maintain eligibility as an active Etnployee 

under this Plan in accordance with Subsections 2.01.a. tlu·ough e. 

( 4) Effective January 1, 2010, a Pmiicipant who has not separated from service but has 

begun a n1andatory comn1encement of Pension paytnents from the Carpenters Pension 

Trust Fund for Nmihem California by virtue of having reached the Required Beginning 

Date 1nay 1naintain eligibility as an Active Employee under this Plan in accordance with 

Subsections 2. 0 l.a. through e. 

3. Section 2.02.fis restated as follows: 

f. Special Conditions for Retired Employees Who Engage in Active Employment During the 

Period June 1, 2009 through December 31, 2013. 

(1) A Participant who is receiving benefit payments from the Carpenters Pension T1ust Fund for 

Nmihern California, who engages in a type of work during the period of June 1, 2009 

tlu·ough December 31, 2013 that requires contributions to this Fund but does not result in 

the suspension of benefit payments from the Carpenters Pension Trust Fund for Northern 

California will not establish eligibility under this Plan. However, if the Retired Employee 

works enough consecutive hours that, in the absence of this rule, he/she would nonnally 

qualify for eligibility as an active Employee, 50% of the health and welfare contributions 

remitted to this Plan on the Retired Employee's behalf will be used to offset his/her self-pay 

contributions for Retiree health coverage. Such offset will only be granted for 50% of 

contributions on up to a maxi1num of 480 hours in a calendar year. 

(2) If the individual is not an eligible Retired Employee in the Retiree Health and Welfare Plan, 

or if the hours worked are less than the number required to earn eligibility under this Plan in 

the absence of this rule, no health and welfare contributions will be credited on the 

individual's behalf. 

(3) A Retiree in the Carpenters Pension Trust Fund for N mihern California who has his or her 

pension suspended may establish and maintain eligibility as an active Employee under this 

Plan in accordance with Subsections 2.01.a. tlu·ough c. 

(4) Effective Janumy 1, 2010, a Pmiicipant who has not separated from service but has begun a 

mandatory commencement of Pension payments from the Carpenters Pension Trust Fund 

for N orthetn California by virtue of having reached the Required Beginning Date may 

1naintain eligibility as an Active Employee under this Plan in accordance with Subsections 

2.02.a. through c. 

4. Section 3.04 is restated in its entirety as follows: 

Section 3.04. Calendar Year Maximum Benefit Amount. Indemnity Medical Benefits and 

Prescription Drug Benefits set forth in Article 5 are limited to an overall con1bined maxilnmn of 

$2,000,000 for each Eligible Individual each calendar year. 



5. Section 3.06.d. is restated as follows to delete the $250 n1aximum on the routine physical 

exmnination benefit: 

d. Routine Physical Examination Benefit - For the Pmiicipant and Spouse Only. Benefits are 

payable at the percentages described in Section 3.02 for a routine physical exan1ination 

provided by a Physician, and any x-rays and laboratory tests provided in connection with the 

physical exan1ination, including pap smears or a prostate specific antigen (PSA) test for 1nale 

Participants age 50 or over. Benefits are limited to one routine physical examination in any 12 

n1onth period for the Pmiicipant and Spouse only. 

6. Section 3.08.h. is restated as follows: 

h. Dental Injury. Services of a Physician (M.D.) or Dentist (D.D.S.) treating an Injury to natural 

teeth. Services must be received within 6 n1onths following the date of Injury (applied without 

respect to when the individual was enrolled in the Plan). Damage to teeth due to chewing or 

biting is not covered under this benefit. 

7. The first paragraph of Section 3.08.k. is restated as follows to delete the $5,000 specific benefit 

maximmn for Hospice Care: 

k. Hospice Care. If an Eligible Individual is terminally ill with a life expectancy of 6 months or 

less, benefits are payable for hospice care provided by an Approved Hospice Program, subject 

to the following conditions and limitations: 

8. Sections 3.08.1. and 3.08.n. are restated as follows to indicate the Chemical Dependency Treatment 

and Mental Health Services benefits provided by United Behavioral Health are subject to the 

overall Calendar Year Maxhnum Benefit Alnount: 

I. Chemical Dependency Treat1nent. These benefits are fully insured by United Behavioral 

Health as outlined in the group agreement between the Trust Fund and United Behavioral 

Health. Eligible Individuals must contact United Behavioral Health prior to obtaining care. 

These benefits are subject to the Indemnity Medical Plan Calendar Year Maximun1 Benefit 

Alnount, but are not subject to the Indemnity Medical Plan Deductible or Annual Out of 

Pocket Maximun1. 

n. Mental Health Services. These benefits are fully insured by United Behavioral Health as 

outlined in the group agreen1ent between the Trust Fund and United Behavioral Health. 

Eligible Individuals must contact United Behavioral Health prior to obtaining care. These 

benefits are subject to the Indemnity Medical Plan Calendar Year Maximmn Benefit Amount, 

but are not subject to the Indemnity Medical Plan Deductible or Annual Out of Pocket 

Maximum. 

9. Section 3.08.n1. is restated as follows to delete the $500 lifetime n1axin1um for diabetes instruction 

progran1s: 

m. Diabetes Instruction Programs, provided the progran1 is recognized as an acceptable program 

by the American Diabetes Association. 

Amendment No. 46, Plan A/R 4


10. Section 5.02 is restated as follows to delete the $75,000 annual maximum for prescription d1ug 

benefits and provide that these benefits are subject to the Indemnity Medical Plan Calendar Year 

Maximun1 Benefit An1ount: 

Section 5.02. Maximum Benefit Amount. Prescription Drug benefits are subject to the 

Indemnity Medical Plan Calendar Year Maximu1n Benefit Amount specified in Section 3.04. 

Board ofTtustees 

of the 


5144147vl/00573.001 




to the 




as restated effective September 1, 2011 

Effective June 1, 2012, the following change is made to the Prescription Drug Benefits set forth in 

Article 5. 

Section 5.01. Benefits is amended by adding the following new Subsection d. 

d. Exception to Brand Name Drug Copayments for New Brand Name Drugs: For any new 

Brand Name Drug approved by the federal Food and Drug Administration (FDA) after June 

1, 2012, including injectable and infusion Drugs, the Co payment is 50% of the cost of the 

Drug for a minimum of 24 months after the Drug has been approved. Subject to approval by 

the Board of Trustees, a new Brand Name Drug may be moved to the Copayment levels 

described in paragraphs (2) through (4) of Subsections a. and b. above prior to the expiration 

of 24 months. If the Pharmacy Benefit Manager' s Pharmacy and Therapeutics committee 

determines that the new FDA approved Drug is a "must not add" Drug, the Copayment will 

remain at 50% of the cost of the Drug indefinitely. 

Executed this ;lJIQun-.. day of~A.J=M-b=t:""lP:~=~------, 2012. 


of the 


5194770vl/00573.001


AMENDI\IIENT NO. 48 

to the· 




as restated effective January 1, 2010 

Effective January 1, 2013, the following changes are made to the Plan. 

1. Section 3.05. Hospital and Facility Benefits is amended by adding a new subsection 3.05.a.(3) 

as follows: 

(3) A maximum of $30,000 is payable for hospital inpatient facility services associated with a 

single hip joint replacement or a single knee joint replacement surgery. 

2. Subsection b. of Section 3.05. Hospital and Facility Benefits is restated as follows: 

b. Outpatient Hospital. Urgent Care Facility. provided that surgical facility services are in 

connection with surgery that is covered by the Plan. The maximum payable benefits listed 

below will apply to the following procedures when received in an outpatient hospital setting: 

(1) Colonoscopy- $1,500 

(2) Arthroscopy- $6,000 

(3) Cataract surgery- $2,000 

3. Subsection c. of Section 3.05. Hospital and Facility Benefits is renumbered subsection d. and a 

new Subsection c. is added as follows: 

c. Licensed Ambulatorv Surgical Facility, provided that surgical facility services are in 

connection with surgery that is covered by the Plan. There is a daily maximum benefit of 

$300 for all services received at a Non-Contract Ambulatory Surgical Facility. 

4. Subsection e. of Section 3.06. Preventive Care Benefits is restated as follows: 

e. Colonoscopy/Siwoidoscopy. The Fund will pay benefits at the percentages described in 

Section 3.02 for colonoscopy and sigmoidoscopy examinations received by Participants and 

Dependent Spouses who are considered at high risk for colon cancer, when recommended by 

a Physician. There is a maximum payable benefit of $1,500 for a colonoscopy received in an 

outpatient hospital setting. 

5. Subsection b. of Section 3.08. Additional Covered Services and Supplies is restated as follows: 

b. Diagnostic radiology and laboratory services subject to the following limitations: 

(1) Services must be ordered by a Physician, including laboratory tests associated with 

diagnosing a viral illness.


(2) For the following outpatient diagnostic imaging services, the Physician must obtain preauthorization 

from the Review Organization: 

(a) CT/CTA 

(b) MRIMRI 

(c) nuclear cardiology 

(d) PET scan 

(e) echocardiography 

6. Section 5.01. Benefits is amended by adding a new subsection e. as follows: 

e. Prior Approval for Proton Pump Inhibitors (PPis) and Cholesterol drugs: Brand Name PPis 

and Cholesterol drugs are subject to prior approval by the Pharmacy Benefit Manager. If 

prior approval is not obtained by the prescribing Physician, no benefits are payable by the 

Plan. If prior approval is received before a prescription is filled for a Brand N arne PPI or 

Cholesterol drug, the Copayment level for Multi-Source Brand Name Drugs as described in 

paragraphs (2) of Subsections a. and b. above will apply. Participants are required to utilize 

the Pharmacy Benefit Manager's defined step therapy before the Plan will pay benefits for 

Brand Name PPis and Cholesterol drugs. 

7. Section 5.04. Covered Expenses is amended by restating subsection g. as follows: 

g. Specialty Drugs, as defined by the Pharmacy Benefit Manager, is subject to the following 

requirements: 

(1) Specialty Drugs are available only from the Pharmacy Benefit Manager's Mail Order 

Pharmacy. Specialty Drugs will not be provided by a retail Participating Pharmacy and 

will not be covered by the Indemnity Medical Plan except for certain Drugs needed in an 

emergency situation; these Drugs are the low molecular weight heparin products that are 

used for blood clots and after hip replacement surgeries. 

(2) Copayments and Supply Limit. The day supply limit for each prescription order is 30 

days. The required Copayments are the Retail Pharmacy Copayments specified in 

Section 5.0l.a. 

8. Section 5.05. Exclusions is amended by restating subsection 1. as follows: 

1. Medications with no federal Food and Drug Administration (FDA) approved indications. Off 

label use of prescriptions (for an indication other than described in the FDA approved drug 

label) will be allowed if prior approval is first obtained from the Pharmacy Benefit Manager.



To the 




Amended and Restated Effective January 1, 2010 

A. Effective January 1, 2015, the following changes are made to the Plan. 

1. Subsection (1) of 2.01.g., Plan A is restated as follows: 

(1) An eligible Participant who is unable to work for a Contributing Employer as a result of 

Disability will have added to his/her Hour Bank sufficient hours of disability credit to extend 

existing eligibility for an additional month up to a maximum of 9 months. However, in order 

to qualify for this Disability extension, the Participant must have earned eligibility for the 

month in which he or she became Disabled and for the next following month. Successive 

Periods of Disability will be considered as separate Periods of Disability when they are: (a) 

separated by at least 60 hours of work for which contributions are required to be made to 

the Fund for Plan A benefits; or (b) due to unrelated causes and separated by at least one 

full day of work for a Contributing Employer. In any other cases, they will be considered as 

one Period of Disability. 

2. Subsection (a) of 7 .02. is restated as follows: 

(a) 

Separated by at least 60 hours of work for which contributions are required to be made to 

the Fund for Plan benefits; or 

3. Subsection (1) of 2.02.e., Plan R, is restated as follows: 

(2) An eligible Plan R Participant who is unable to work for a Contributing Employer as a result 

of Disability will be given credit to extend existing eligibility for each month he/she remains 

Disabled up to a maximum of 4 months. However, in order to qualify for this Disability 

extension, the Participant must have earned eligibility for the month in which he/she 

became Disabled and for the next following month. Successive Periods of Disability will be 

considered as separate Periods of Disability when they are: (a) separated by at least 60 

hours of work for which contributions are required to be made to the Fund for Plan R 

benefits; or (b) due to unrelated causes and separated by at least one full day of work for a 

Contributing Employer. In any other cases, they will be considered as one Period of 

Disability. 

B. Effective April 14, 2003 (and revised September 1, 2013), the following changes are made to the Plan 

to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended 

by the Health Information Technology for Economic and Clinical Health Act (HITECH): 

1. Article 10. General Provisions is modified by revising section 10.09, as follows: 

Section 10.09. Privacy and Right to Receive and Release Necessary Information.


a. For the purpose of determining the applicability of and implementation of the terms of 

Sections 8.03 through 8.06 dealing with Coordination of Benefits of this Plan or any provision 

of similar purpose of any other plan, the Plan may, to the extent consistent with Federal and 

state privacy laws (to the extent applicable) and the Plan's Privacy Procedures, release to or 

obtain from an insurance company or other organization or person any information, with 

respect to any person, that the Plan deems to be necessary for such purposes. 

b. The Trustees and appropriate professionals retained by the Plan, may, to the extent necessary 

and in accordance with Federal and state privacy laws {to the extent applicable) and the Plan's 

Privacy Procedures, have access to such Protected Health Information regarding Participants 

and Dependents as is reasonably necessary to make eligibility, payment, claims and appeals 

decisions, or as otherwise necessary to the administration of the Plan. 

c. The Trustees shall develop Privacy Procedures in accordance with The Health Insurance 

Portability and Accountability Act of 1996 (HIPAA) and other applicable laws, and shall furnish 

to each Participant and Dependent a Notice of Privacy Practices. Such policies and practices 

shall be consistent with applicable Federal and state laws. 

d. Except as permitted by HIPAA, the Plan will only use or disclose your PHI for marketing 

purposes or sell (exchange) your PHI for remuneration (payment), with your written 

authorization. The following are permitted and required uses and disclosures of Protected 

Health Information, as that term is defined in HIPAA, that may be made by the Plan sponsor, 

the Board ofTrustees. 

(1) The Board of Trustees may make the following permitted and required disclosures of 

Protected Health Information. All disclosures shall be of the Minimum Necessary 

information, as that term is defined under HIPAA, except in the case of Subsections (o) 

through (s) below. 

Permitted Disclosure Purposes: 

(a) 

(b) 

(c) 

(d) 

(e) 

(f) 

(g) 

(h) 

(i) 

(j) 

As necessary for claims payment, Plan operations and treatment, including for the 

purpose of de-identifying information for further permitted disclosure. 

Determining eligibility and amount of benefits. 

Determining medical necessity, utilization reviews, and precertifications. 

Processing claims, auditing claims, investigating claims, responding to Participant 

inquiries regarding claims, and insuring proper claims payment. 

Subrogation and other third-party recovery processing. 

Determining proper employer contributions. 

Processing and determining stop loss coverage. 

Claims and appeals processing. 

Quality assessment, case management, provider rating, underwriting (the Plan 

does not use or disclose PHI that is genetic information for underwriting 

purposes), enrollment and premium rating, patient safety activities, and other 

related activities. 

Legal and auditing services, including Plan compliance.


(k) 

(I) 

(m) 

(n) 

(o) 

(p) 

Plan design analysis, including cost analysis and Plan change evaluations. 

Implementation of HIPAA and other applicable laws. 

Tax and other regulatory filings. 

Disclosures to the covered individual. 

Disclosures that are subject to a specific written authorization from the covered 

individual. 

Uses that are incident to a use or disclosure otherwise permitted or required by 

law. 

Required Disclosures: 

(a) To the covered individual, when requested, to the extent required by law. 

(b) When requested, to the Secretary of Health and Human Services; 

(c) Any other instance in which HIPAA explicitly permits the use or disclosure without 

authorization. 

(2) Further, the Board of Trustees will: 

(a) 

(b) 

(c) 

(d) 

(e) 

(f) 

(g) 

(h) 

(i) 

Not use or further disclose the information other than as permitted or required by 

the Rules and Regulations and Privacy Procedures, or as required by law. 

Ensure that any agents to whom it provides Protected Health Information 

received from the Plan agree to the same restrictions and conditions that apply to 

the Trustees with respect to such information. 

Not use or disclose the information for employment-related actions and decisions 

or in connection with any other benefit or employee benefit plan of the Plan 

sponsor. 

Report to the Plan any use or disclosure of the information that is inconsistent 

with the uses or disclosures provided for of which it becomes aware. 

Make available Protected Health Information in accordance with HIPAA. 

Make available Protected Health Information for amendment by Participants and 

Dependents and incorporate any amendments to Protected Health Information in 

accordance with HIPAA. 

Make available the information required to provide an accounting of non-routine 

disclosures in accordance with HIPAA. 

Make its internal practices, books and records relating to the use and disclosure of 

Protected Health Information received form the Plan available to the Secretary of 

Health and Human Services or any other officer or employee of HHS to whom the 

authority involved has been delegated for purposes of determining compliance by 

the Plan with the regulations requiring the Plan's Privacy Procedures and this 

Section. 

To the extent feasible, return or destroy all Protected Health Information received 

from the Plan that the Trustee(s) still maintain in any form and retain no copies of 

such information when no longer needed for the purpose for which disclosure was


(j) 

made, except that, if such return or destruction is not feasible, limit further uses 

and disclosures to those purposes that make the return or destruction of the 

information infeasible. 

Ensure the adequate separating required by the following Section 10.09.d.(3). 

(3) The Board of Trustees and the Plan shall be treated as separate and distinct entities for 

purposes of these privacy rules. To that end, only the following persons or entities shall 

be authorized by the Trustees to have access to Protected Health Information and such 

access shall be solely for the specific Plan-related functions performed by such persons 

or entities. 

(a) 

(b) 

(c) 

(d) 

(e) 

(f) 

(g) 

(h) 

(i) 

(j) 

(k) 

The Plan's administrator and its employees, including claims adjusters, benefits 

and eligibility staff, and accounting personnel. 

Utilization review and case management providers and their employees. 

Claims repricing provider and its employees, including health services purchasing 

coalitions. 

The Plan's business associates, including attorneys, actuaries, consultants and 

accountants. 

PPO organizations and stop loss carriers. 

Medical review consultants and firms. 

Prescription drug benefit providers. 

Dental and vision plan providers. 

Mental health and substance abuse treatment providers. 

Other service providers that require Protected Health Information to perform 

services for the Plan. 

Off-site storage providers who maintain the Plan's archival records. 

(4) Noncompliance. In the event any person or entity to which the Plan has provided 

Protected Health Information in accordance with this Subsection d. uses or discloses 

such information in a manner inconsistent with the Plan, its Privacy Procedures, or 

applicable law, the Trustees shall have the right to: 

(a) 

(b) 

(c) 

(d) 

Notify such person or entity in writing of such violation and demand immediate 

correction and remedial measures be taken to correct such use or disclosure. 

Assess against such person or entity the actual costs of the corrective or remedial 

action described in Subsection {a). 

Send a letter of reprimand to any such person or entity that repeatedly commits 

such violations. 

Take such additional appropriate action including, to the extent feasible, 

terminating the Plan's relationship with such person or entity, or reporting such 

violations to the Secretary of Health and Human Services. 

e. Security Regulations. The Board will implement measures to comply with the security 

regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996,


45 C.F.R. Parts 160, 162 and 164 (the "Security Regulations"). The following provisions apply 

to Electronic Protected Health Information ("ePHI") that is created, received, maintained or 

transmitted by the Plan, except for ePHI that: (1) the Plan receives pursuant to an appropriate 

authorization (as described in 45 C.F.R. section 164.504(f)(1)(ii) or (iii)), or (2) that qualifies as 

Summary Health Information and that it receives for the purpose of either (a) obtaining 

premium bids for providing health insurance coverage under the Plan, or (b) modifying, 

amending or terminating the Plan (as authorized under 45 C.F.R. section 164.508). 

The Board will, in accordance with the Security Regulations: 

1) Implement administrative, physical and technical safeguards that reasonably and 

appropriately protect the confidentiality, integrity and availability of the ePHI that the 

Plan creates, receives, maintains or transmits. 

2) Ensure that "adequate separation" is supported by reasonable and appropriate security 

measures. "Adequate separation" means the Plan will use ePHI only for Plan 

administration activities and not for employment related actions or for any purpose 

unrelated to Plan administration. Any Trustee, Plan professional, employee or other 

fiduciary of the Plan who uses or discloses ePHI in violation of the Plan's security or 

privacy policies and procedures or this Plan provision will be subject to the Plan's 

disciplinary procedures as described in Section 10.09.d. (4). 

3) Ensure that any agent or subcontractor to whom the Plan provides ePHI agrees to 

implement reasonable and appropriate security measures to protect the information. 

4) The Plan Administrator will report to the Board any Security Incident of which he 

becomes aware. 

Certification: By signing below, the Board of Trustees hereby certifies the adoption of this 

Amendment and the Board's agreement to its terms in order to comply with the Health Insurance 

Portability and Accountability Act of 1996. 

Executed this \ o..,-»'> day of ___ ____:.M_,uo\\j=\-------, 2014. 

Board ofTrustees 

of the 

Carpenters Health and Welfare Trust Fund for California

ERISA - Plan A/R 1/13/2015










TO THE 

REVISED AND RESTATED PENSION PLAN FOR THE CARPENTERS 

PENSION TRUST FUND FOR NORTHEIL~ CALIFORNIA 

(Last Restated June 1, 2012) 

The Board of Trustees of the Carpenters Pension Trust Fund for Northern California has voted to amend 

the Revised and Restated Pension Plan for the Carpenters Pension Trust Fund for Northern California to 

modify the Review of Appeal rules. 

1. Effective March 1, 2014 , Section 10.04.d is amended as follows: 

d. Review of Appeal. 

A benefit determination on review will be made by the Trustees or by a committee designated by 

them no later than the date of the quarterly meeting of the Board of Trustees or committee that 

immediately follows the Fund Office's receipt of the request for review unless the request for 

review is filed within thirty (30) days preceding the date of such meeting. In such case, a benefit 

determination will be made no later than the date of the second meeting following the Fund 

Office's receipt of the request for review. If special circumstances require a further extension of 

time for processing, a benefit determination will be rendered no later than the third meeting 

following the Fund Office's receipt of the request for review and the Board of Trustees will 

provide the petitioner with a written notice of the extension, describing the special circumstances 

and the date by which the benefit determination will be made, prior to the commencement of the 

extension. The Board of Trustees will notify the petitioner of the benefit determination as soon as 

possible but not later than 5 days after the benefit determination is made. 

The notification of a benefit determination upon review will be in writing and will include the 

reason(s) for the determination, including references to the specific Plan provisions on which the 

determination is based. It will also include a statement that the petitioner is entitled to receive, 

upon request and free of charge, reasonable access to, and copies of all documents, records and 

other information relevant to the claim for benefits. The notification of a benefit determination 

with regard to a Section 3.08 disability benefit will include the above, along with the specific 

rule, guideline, protocol or other similar criterion relied upon in making the adverse 

determination. 

The period of time within which a benefit determination review is required to be made by the 

Trustees or by a committee designated by them will begin at the time the request for the benefit 

determination review is filed with the Fund Office without regard to whether all the information 

necessary to make a benefit determination review accompanies the filing. 

In the event that the period for the benefit determination review is extended due to a petitioner's 

failure to submit information necessary to make such a determination, the period for making the 

benefit determination review will be suspended from the date on which the notification of the 

extension is sent to the petitioner until the date on which the petitioner responds to the request 

for additional information.


Amendment No. 89 to the 

Revised and Restated Pension Plan For The Carpenters 

Pension Trust Fund for Northern California 

The denial of a claim to which the right to review has been waived, or the decision of the Board 

of Trustees or its designated committee with respect to a petition for review, is final and binding 

upon all parties, subject only to any civil action the applicant may bring under §502(a) of 

ERISA. Following issuance of a written decision of the Board of Trustees on an appeal, there is 

no further right of appeal to the Board of Trustees or right to arbitration. 

No legal action may be commenced or maintained against the Pension Fund and/or the Board of 

Trustees more than two (2) years after a claim has been denied. 

However, a petitioner may re-establish his or her entitlement to benefits at a later date based on 

additional information and evidence which was not available to him or her at the time of the 

decision of the Board of Trustees. 

2. Except as hereinabove amended, the provisions of the Plan shall continue in full force and effect. 

l/749845 

Page 2 of2



TO THE 

REVISED AND RESTATED PENSION PLAN FOR THE CARPENTERS 

PENSION TRUST FUND FOR NORTHERN CALIFOR.l\IIA 

(last restated June 1, 2012) 

The Board of Trustees of the Carpenters Pension Trust Fund for Northern California has voted to amend 

the Revised and Restated Pension Plan for the Carpenters Pension Trust Fund for Northern California to 

modify the rules regarding Future Service Eligibility Credit for Non-Working Periods. 

1. Effective January 1, 2015 Section 6.04.a.(5) is added as follows: 

( 5) Commencing January 1, 2015, such periods of absence are to be credited at the rate which is 

the lesser of: 

(a) 35 hours per week; or 

(b) the average hours worked by the Participant in accordance with Section 1.21. 

(including any Hours for Qualified Military Service) during the twenty-four full 

calendar months immediately preceding the period of absence (notwithstanding the 

length of the period of employment immediately preceding such period). For 

purposes of this provision, the average hours worked in the two calendar years prior 

to the "Credit for Non-Working Periods" application may be used (including any 

Hours for Qualified Military Service), if greater than the previous twenty-four 

calendar month average. 

2. Effective January 1, 2015 Section 6.04.b. is restated as follows: 

b. Such circumstances are as follows: 

(1) Qualified Military Service. Service in any of the Armed Forces of the United States, provided 

the Participant made himself available for Covered Employment in Northern California 

within the period during which he retains reemployment rights under the Uniformed Services 

Employment and Reemployment Rights Act of 1994 ("USERRA"). 

Future Service Eligibility Credit will be credited for such Qualified Military Service based on 

the average number of hours worked in a week by the Participant during the twelve-month 

period immediately preceding such military service, but not less than the hours per week 

determined in accordance with Section 6.04.a. 

(2) Disability for the period in which California State Disability Insurance (SDI) benefits were 

paid or which constituted a valid waiting period for such benefits. 

(3) Disability for the period for which Workers' Compensation temporary disability benefits or 

temporary disability benefits under the Longshoremen's and Harbor Workers' Compensation 

Act were paid, or which constituted a valid waiting period for such benefits.


(4) Effective January 1, 2015, Future Service Eligibility Credit for Non-Working Periods under 

paragraphs (2) and (3) above ("Disability Credit") shall be granted to eligible Participants: 

(a) Who have at least 7 full Eligibility Credits (without a Permanent Break in Service) 

based on Hours of Work in Northern California or Hours granted for Qualified 

Military Service, and 

(b) Who have not previously qualified for Disability Credit Hours that exceed 20% of the 

total Hours of Work in Covered Employment and Hours in Qualified Military Service 

since the Contribution Date as of the "onset of disability date", which is the date the 

Participant began receiving State Disability Insurance Benefits or Workers' 

Compensation Benefits. 

(c) For Non-Working periods with an "onset of disability date" after January 1, 2015, up 

to the limit set forth in Section 6.04.b.(4)(b), even if the period of Disability extends 

beyond the maximum allowed under this Subsection. 

(5) Notwithstanding any other provisions herein, the maximum Disability Credit Hours a 

Participant can accrue towards Future Service Eligibility Credit for Non-Working Periods 

under Sections 6.04.b.(2) through (4) above is the greater of: 

(a) 20% of the total Hours of Work in Covered Employment and Hours in Qualified 

Military Service since the Contribution Date, or 

(b) Disability Hours Credited for qualified Non-Working periods as of January 1, 2015, 

even if greater than 20% of the total Hours of Work in Covered Employment and 

Hours in Qualified Military Service since the Contribution Date. 

In order to secure credit for the periods of disability as provided in this Section, a Participant 

must give written notice to the Fund Office within 12 months of the onset of disability, and 

furnish in writing such information and proof concerning such disability as the Board may in its 

sole discretion determine. 

The Contributions required to pay for the hours credited for the Non-Working Periods as 

described above will be allocated from the general assets of the Fund, and no Contributing 

Employer will be liable to make Contributions for such hours. 

1/749845



to the 

Restated Pension Plan for the 

Carpenters Pension Trust 

for Northern California 

The Board of Trustees of the Carpenters Pension Trust Fund for Northern California has voted to 

amend the Restated Pension Plan for the Carpenters Pension Trust Fund for Northern California 

to incorporate changes to the Percentage of Contribution Factor. 

Effective July 1, 2014, Appendix 10 is revfsed to read as follows: 

Percentage of Contribution Factor 

Effective Date 

Percentage of Contribution Factor 

January 1, 2007 to June 30, 2011 1.75% 

July 1, 2011 to June 30, 2012 1.44% 

July 1, 2012 to June 30, 2013 1.39% 

July 1, 2013 to June 30, 2014 1.36% 

July 1, 2014 to June 30, 2015 1.31% 

July 1, 2015 to June 30, 2016 1.29% 

July 1, 2016 to June 30, 2017 1.27% 

July 1, 2017 to June 30, 2018 1.25% 

July 1, 2018 1.23% 

Executed this ~day of Jl;ne 2014.





to the 

Restated Plan for the 


The Board ofTrustees ofthe Carpenters Annuity Trust Fund for Northern California has voted 

to amend the Restated Plan for the Carpenters Annuity Trust Fund for Northern California (the 

"Plan") as follows, pursuant to the request made by the Internal Revenue Service by letter dated 

May 31, 2012 in response to the Trustees' request for a determination on the Plan: 

1. Section 3.4 of the Plan is amended by adding a new subsection (D) thereto to read as 

follows: 

(D) 

Ifa Participant dies while performing Qualified Military Service on or after 

January I, 2007, the survivors ofthe Participant are entitled to any additional 

benefits (other than benefit accruals relating to the period ofqualified military 

service) provided under the Plan had the Participant resumed employment and 

then terminated employment on account ofdeath. 

2. A new Section 11 is added to the Plan to read as follows: 

SECTION 11. TOP-HEAVY RULES 

11.1 Definitions. For purposes ofthis Section 11, the following words and phrases shall have 

the meaning stated below unless a different meaning is clearly required by the context: 

(A) 

Key Employee 

(1) In determining whether the Plan is top-heavy for Plan years beginning after 

December 31, 2001, Key Employee means any Employee or former employee 

(including any deceased employee) who at any time during the Plan year that 

includes the determination date is an officer ofthe Employer having an annual 

Compensation greater than $130,000 (as adjusted under Section 416(i)(l) of 

the Internal Revenue Code (the "Code") for Plan years beginning after 

December 31, 2002), a 5-percent owner ofthe Employer, or a I-percent owner 

of the Employer having an annual Compensation of more than $150,000. In 

determining whether a plan is top-heavy for plan years beginning before 

January 1, 2002, Key Employee means any employee or former employee 

(including any deceased employee) who at any time during the 5-year period 

ending on the determination date, is an officer of the Employer having an 

annual Compensation that exceeds 50-percent of the dollar limitation under 

Section 415(b)(I)(A), an owner (or considered an owner under Section 318) 

of one of the ten largest interests in the Employer if such individual's 

Compensation exceeds 100 percent of the dollar limitation under Section 

415(c)(I)(A), a 5-percent owner ofthe Employer, or a I-percent owner of the


Employer who has an annual Compensation of more than $150,000. For 

purposes of this paragraph (l), annual Compensation means Compensation as 

defined in Section 1.12. 

The determination of who is a Key Employee will be made in accordance with 

Section 416(i)(I) of the Code and the applicable regulations and other guidance of 

general applicability issued thereunder. 

(B) 

Top-Heavy Plan 

This Plan is top-heavy if any ofthe following conditions exists: 

(l) 

Ifthe top-heavy ratio for this Plan exceeds 60 percent and this Plan is not part 

ofany required aggregation group or permissive aggregation group ofplans. 

(2) If this Plan is a part of a required aggregation group of plans but not part of a 

permissive aggregation group and the top-heavy ratio for the group of plans 

exceeds 60 percent. 

(3) If this Plan is a part of a required aggregation group and part of a permissive 

aggregation group of plans and the top-heavy ratio for the permissive 

aggregation group exceeds 60 percent. 

(C) 

Top-Heavy Ratio. 

(l) 

If the Employer maintains one or more defined contribution plans (including 

any Simplified Employee Pension Plan) and an Employer has not maintained 

any defined benefit plan which during the 5-year period ending on the 

determination date(s) has or has had accrued benefits, the top-heavy ratio for 

this Plan alone or for the required or permissive aggregation group as 

appropriate is a fraction, the numerator of which is the sum of the account 

balances of all Key Employees as of the determination date(s) (including any 

part of any account balance distributed in the I-year period ending on the 

determination date(s» (5-year period ending on the determination date in the 

case of a distribution made for a reason other than severance from 

employment, death or disability and in determining whether the Plan is topheavy 

for Plan years beginning before January I, 2002), and the denominator 

ofwhich is the sum of all account balances (including any part of any account 

balance distributed in the I-year period ending on the determination date(s) 

(5-year period ending on the determination date in the case of a distribution 

made for a reason other than severance from employment, death or disability 

and in determining whether the Plan is top-heavy for Plan years beginning 

before January 1,2002), both computed in accordance with Section 416 ofthe 

Code and the regulations thereunder. Both the numerator and denominator of 

the top-heavy ratio are increased to reflect any contribution not actually made 

as ofthe determination date, but which is required to be taken into account on 

that date under Section 416 ofthe Code and the regulations thereunder. 

(2) If an Employer maintains one or more defined contribution plans (including 

any Simplified Employee Pension Plan) and the Employer maintains or has 

2


maintained one or more defined benefit plans which during the 5-year period 

ending on the determination date(s) has or has had any accrued benefits, the 

top-heavy ratio for any required or permissive aggregation group as 

appropriate is a fraction, the numerator of which is the sum of account 

balances under the aggregated defined contribution plan or plans for all Key 

Employees, determined in accordance with (I) above, and the present value of 

accrued benefits under the aggregated defined benefit plan or plans for all Key 

Employees as of the determination date(s), and the denominator of which is 

the sum of the account balances under the aggregated defined contribution 

plan or plans for all Participants, determined in accordance with (I) above, 

and the present value of accrued benefits under the defined benefit plan or 

plans for all Participants as of the determination date(s), all determined in 

accordance with Section 416 ofthe Code and the regulations thereunder. The 

accrued benefits under a defined benefit plan in both the numerator and 

denominator of the top-heavy ratio are increased for any distribution of an 

accrued benefit made in the I-year period ending on the determination date (5 

year period ending on the determination date in the case ofa distribution made 

for a reason other than severance from employment, death or disability and in 

determining whether the Plan is top-heavy for Plan years beginning before 

January I, 2002). 

(3) For purposes of (1) and (2) above the value of account balances and the 

present value of accrued benefits will be determined as of the most recent 

valuation date that falls within or ends with the 12-month period ending on the 

determination date, except as provided in Section 416 of the Code and the 

regulations thereunder for the first and second Plan years of a defined benefit 

plan. The account balances and accrued benefits of a Participant (i) who is not 

a Key Employee but who was a Key Employee in a prior year, or (ii) who has 

not been credited with at least one hour of service with any Employer 

maintaining the Plan at any time during the I-year period (5-year period in 

determining whether the Plan is top-heavy for Plan years beginning before 

January 1, 2002) ending on the determination date will be disregarded. The 

calculation of the top-heavy ratio, and the extent to which distributions, 

rollovers, and transfers are taken into account will be made in accordance with 

Section 416 of the Code and the regulations thereunder. Deductible employee 

contributions will not be taken into account for purposes of computing the 

top-heavy ratio. When aggregating plans the value of account balances and 

accrued benefits will be calculated with reference to the determination dates 

that fall within the same calendar year. 

The accrued benefit of a Participant other than a Key Employee shall be 

determined under (i) the method, if any, that uniformly applies for accrual 

purposes under all defined benefit plans maintained by the Employer, or (ii) if 

there is no such method, as if such benefit accrued not more rapid! y than the 

slowest accrual rate permitted under the fractional rule of Section 

41 I(b)(l)(C) ofthe Code. 

3


(0) Permissive Aggregation Group. 

The required aggregation group ofplans plus any other plan or plans of an Employer 

which, when considered as a group with the required aggregation group, would 

continue to satisfy the requirements of Section 40 1(a)(4) and 410 ofthe Code. 

(E) 

Required Aggregation Group. 

(l) 

Each qualified plan of an Employer in which at least one Key Employee 

participates or participated at any time during the plan year containing the 

determination date or any of the four preceding plan years (regardless of 

whether the plan has terminated), and 

(2) any other qualified plan ofthe Employer which enables a plan described in (l) 

to meet the requirements of Section 401(a)(4) or 410 ofthe Code. 

(F) 

Determination Date. 

For any Plan year subsequent to the first Plan year, the last day ofthe preceding Plan 

year. For the first Plan Year ofthe Plan, the last day ofthat year. 

(G) 

Valuation Date. 

The last day ofeach Plan year. 

11.2 Minimum Benefits 

(A) 

(B) 

(C) 

Except as otherwise provided in (C) and (0) below, the Employer contributions and 

forfeitures allocated on behalfof any Participant who is not a Key Employee shall not 

be less than the lesser of three percent of such Participant's Compensation or in the 

case where the Employer has no defined benefit plan which designates this Plan to 

satisfy Section 401 of the Code, the largest percentage ofEmployer contributions and 

forfeitures, as a percentage of Key Employee's Compensation, as limited by Section 

401 (a)(l7) ofthe Code, allocated on behalf of any Key Employee for that year. The 

minimum allocation is determined without regard to any Social Security contribution. 

This minimum allocation shall be made even though, under other Plan provisions, the 

Participant would not otherwise be entitled to receive an allocation, or would have 

received a lesser allocation for the year because of (i) the Participant's failure to 

complete 1,000 hours of service (or any equivalent provided in the Plan), or (ii) the 

Participant's failure to make mandatory employee contributions to the Plan, or (iii) 

Compensation less than a stated amount. 

For purposes of computing the minimum allocation, Compensation shall mean 

Compensation as defined in Section 1.12 as limited by Section 401(a)(l7) of the 

Code, but shall mean Compensation earned as an Employer for the whole year. 

The provisions in (A) above shall not apply to any Participant who was not employed 

by the Employer on the last day ofthe Plan year. 

4


CD) 

The provision in CA) above shall not apply to any Participant to the extent the 

Participant is covered under any other plan or plans of the Employer and the 

Employer has provided that the minimum allocation or benefit requirement applicable 

to top-heavy plans will be met in the other plan or plans. 

11.3 Minimum Vesting 

The Participants in this Plan are always 100% vested. 

The undersigned Chairman and Co-Chairman of the Board of Trustees of the Carpenters 

Annuity Trust Fund for Northern California do hereby certify that the foregoing Amendment 

No.5 the Restated Plan for the Carpenters Annuity Trust Fund for Northern California was 

duly ~do ted b the Board ofTrustees at a meeting held on October 30, 2012. 

5

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