ITPEU HEALTH & WELFARE Enrollment Form

ITPEU HEALTH & WELFARE

Enrollment Form
Social Security Number*
Name*

First NameMiddle NameLast Name and Suffix
Email
example@example.com
Address*

Number and Street

Street Address Line 2

CityState

Zip Code
Your Employer*
Mothers Maiden Name
Last Name
Gender*

MaleFemale
Status

SingleMarried
Birth Date

MonthDayYear
Date Employed*

MonthDayYear
Date
Name of Spouse
Spouse Date Of Birth

MonthDayYear
Date
Spouse Social Security #
I REVOKE ALL PREVIOUS DESIGNATIONS AND MAKE THE FOLLOWING DESIGNATION WITH RESPECT TO HEALTH & WELFARE BENEFITS. I UNDERSTAND THAT THIS DESIGNATION WILL BECOME EFFECTIVE WHEN RECEIVED IN THE PLAN'S OFFICE.
Name of Beneficiary(s)
Relationship
(Number, Street, City, State & Zip Code)
Contingent Beneficiary(s)
Relationship
(Number, Street, City, State & Zip Code)

List your Dependents

Marriage Certificate and Dependent Birth Certificate Upload

Cancelof
Your Signature*

Clear
Date

MonthDayYear
Date
YOU MUST SUBMIT COPY OF MARRIAGE CERTIFICATE & BIRTH CERTIFICATE FOR DEPENDENT COVERAGE. IF ADDITIONAL SPACE IS NEEDED, PLEASE ATTACH TO ENROLLMENT CARD.

I, recognize that under the collective bargaining agreement negotiated on my behalf by ITPEU, my employer is obligated to make certain contributions to the ITPEU Health & Welfare Fund for each hour that I am employed. In order to protect my coverage under the benefit programs established by the Trustees of the ITPEU Health & Welfare Fund. I want to insure that contributions to those programs continue for every hour of covered service which I perform for my employer. Accordingly, if it becomes necessary for the U.S. Department of Labor and/or its representatives to administer the distribution of wages and fringe benefits from funds payable under the service contract covering my employer; I hereby authorize and direct the U.S. Department of Labor and/or its representatives to pay directly to the Trustees of the ITPEU Health & Welfare Fund from any funds otherwise due me, such amounts as are necessary to satisfy the contribution rates specified in the appropriate collective bargaining agreement covering my employment for each hour of employment I perform for my employer under the below named Service Contract
(Name & Location)
Employee Signature*

Clear
Date

MonthDayYear
Date
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