Ironworkers 808 - Insurance Enrollment Form

Mailing Address: P.O. Box 1449 Goodlottsville, TN 37070-1449

Street Address: 2001 Caldwell Drive Goodlettsville, TN 37072-2328

ENROLLMENT FORM

Please complete this form in its entirety, front and back and return it in the enclosed envelope. The information requested below is very important as it provides the Plan office with current information about you and your dependents. Please only list those dependents who meet the definition of an Eligible Dependent, as that term is defined in your Summary Pian Description. This form also allows you to designate a beneficiary for the purpose of receiving benefits from the Fund upon your death. Please sign and date the form.

In order to enroll dependents below for coverage under the Plan, please provide copies of marriage certificate and birth certificate(s) (For Children only The Plan office will not verify dependent coverage to providers or process claims on their behalf without this documentation. If you have previously provided this information for each of the dependents you list below, it is los necessary for you to submit it again.

Participant Name:*

First NameLast Name

Date of Birth:*

Date

Sex:*

Address:*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security No.*

Local Union No.*

Phone Number:*

Participant's Email Address:*

example@example.com

Spouse's Name:*

Spouse's Social Security No.*

Date of Birth (Spouse):*

Date

Spouse's Email Address:*

example@example.com

Date of Marriage:*

Date

Phone Number (Spouse):*

Dependent Children:

	Name of Dependent	Birthdate	SSN	Sex
Dependent #1
Dependent #2
Dependent #3
Dependent #4
Dependent #5

Beneficiary Name:*

Address (if different):

Social Security No.*

Contingent Beneficiary Name(s):

Social Security No.

Name of Covered Individual:

Group No:

Contract No.

Name/Address of Insurance Company or Plan:

Telephone number of Insurance Company or Plan:

Effective date of coverage

Date

Termination date of coverage (if applicable)

Date

Type of Coverage:

Is your other coverage PPO or HMO?

Name of Covered Individual:

Medicare Health Insurance (HIC) Number:

Enrolled In:

Part APart BPart D

Medical Eligibility based on:

AgeDisibilityEnd Stage Renal Disease

Signature*

Date*

Date

SOUTHEASTERN IRON WORKERS HEALTH CARE PLAN - Enrollment Form

INFORMATION REGARDING YOU AND YOUR DEPENDENTS

DESIGNATION OF BENEFICIARY

IF YOU OR A DEPENDENT HAVE OTHER HEALTH COVERAGE, COMPLETE THIS SECTION

IF YOU OR A DEPENDENT HAVE MEDICARE COVERAGE, COMPLETE THIS SECTION

THIS FORM MUST BE SIGNED AND DATED BY THE PARTICIPANT