Ironworkers 118 - Active Employee Benefit Enrollment Form

DEPENDENTS TO BE ENROLLED

CALIFORNIA IRONWORKERS FIELD WELFARE PLAN

Member Select One Benefit Option Below

FUND OFFICE USE ONLY

CALIFORNIA IRONWORKERS FIELD WELFARE PLAN

131 No. Molino Avenue Suite 330 Pasadena, CA 91101 Tel: (626) 792-7337 or (800) 527-4613
Active Employee Benefit Enrollment Form
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last 4 SSN:*
Telephone Number:*
Format: (000) 000-0000.
Date of Birth:*

MonthDayYear
Date
Local Union:*
MaleFemale
SingleMarried/Domestic PartnershipDivorcedLegally Separated
Name of Spouse/Domestic Partner
Date of Divorce

MonthDayYear
Date
Date of Legal Separation

MonthDayYear
Date
For any dependents to be eligible for benefits, the following documentation must be submitted along with this completed Enrollment Form:

(Please do not send original documents, copies are sufficient)

Spouse: a copy of the certified and recorded marriage certificate and a copy of spouse's social security card (marriage license is not acceptable).

Domestic Partner: a copy of the registered Domestic Partnership and a copy of domestic partner's social security card.

Natural Child: a copy of the certified and recorded birth certificate and a copy of the dependents child's social security card.

Stepchild: a copy of the certified and recorded birth certificate and a copy of the dependents child's social security card; member mustbe legally married to the child's birth parent.

Legal Guardianship/Adoption: a copy of the child's certified and recorded birth certificate in addition to any pertinent court documentation.

This information must be received prior to eligibility being granted for any dependent, regardless of the member's eligibility status. Also, if there has been a change in your marital status since the completion of your last Enrollment Form, please be advised that we MUST receive a complete copy of your Final Judgment of Divorce in order for an ex-spouse to be terminated or for eligibility to be granted to a new spouse. Please list below all eligible dependents (please refer to your Health and Welfare Summary Plan Description for a list of qualifying dependents), which who you would like to be enrolled for eligibility under the California Ironworkers Field Welfare Plan.
File Upload (make sure text in photos is legible)

Multiple files can be selected
Cancelof
DEPENDENTS TO BE ENROLLED

Dependent Enrollment

OTHER COVERAGE - You must notify the Trust Fund Office in writing if you or your dependent(s) obtain other coverage, including Medicare
YesNo
Part APart B
Name of Other Insurance Company Plan/Employer:
Name of Insured:
YesNo
Part APart B
Name of Other Insurance Company Plan/Employer:
Name of Insured:
YesNo
Part APart B
Name of Other Insurance Company Plan/Employer:
Name of Insured:
Name of Other Insurance Company Plan/Employer

I understand that the information furnished is for eligibility purposes, and I certify that the information provided on this form is correct and complete, and may be relied on in the enrollment and payment of benefits for my said dependent(s
Member Signature:*

Clear
Date:*

MonthDayYear
Date
Member Select One Benefit Option Below
FFS (Anthem Blue Cross)Kaiser Permanente
New ParticipantOpen EnrollmentNew DependentCOBRA
Date of qualifying event (If selected COBRA)

MonthDayYear
Date
I certify under penalty of perjury, under the laws of California that the information given in this form is true, correct, and complete to the best of my knowledge.
Date*

MonthDayYear
Date
Signature*

Clear
Member Last 4 SSN*
Member Name*
Kaiser Foundation Health Plan, Inc., Arbitration Agreement*

I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation, and any other claims that cannot be subject to binding arbitration under governing law) and dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of tor related to membership in KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage.
Signature:

Clear
Date:

MonthDayYear
Date
FUND OFFICE USE ONLY
EFF Date

MonthDayYear
Date
HDIC:
Eligibility Code:
Group Number:
Should be Empty:

DOB (mm/dd/yyyy)

Relationship

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5