Benefit Information Change Form

Welcome to the Teamsters Local 237 Benefit Information Change Form
What type of amendment would you like to make?*
Before you begin, you may need one or more of the following documents for all persons being enrolled:
- Birth Certificate
- Social Security Card
- Marriage Certificate
- Domestic Partnership Registration Certficate
- Certification Letter from the City Health Benefits Program
If at this time you would not like to enroll any dependents, please fill the form out for yourself. You can add more dependants at another time.

BENEFIT INFORMATION CHANGE FORM

TEAMSTERS LOCAL 237 WELFARE FUNDS * 216 West 14th Street 3rd Floor, New York, NY 10011
This information is essential for accurate and efficiant administration of the benefits for which you and your dependents are or will be eligible for under the Welfare plan. BE SURE TO ANSWER ALL THE QUESTIONS COMPLETELY AND ACCURATELY. This information will be treated confidentially, except that it may be transmitted to third parties as necessary for the administration of benefits or as required by law.
SSN*
No Dashes
Gender*
Last Name*
First Name*
Middle Initial
Birthday*

MonthDayYear
Address*
Apt
City*
State*
Initials Only (i.e. NY, NY, CT)
Zip Code*
Email
example@example.com
Phone*
No Dashes
Marital Status*

Spouse/Domestic Partner Information
Spouse/Domestic Partner Information
Date of Marriage/Domestic Partnership*

MonthDayYear
Date
Last Name*
First Name*
Middle Initial
Gender*
Birthday*

MonthDayYear
SSN*
No Dashes
Employer Optional
Health Insurance Carrier (optional)
Marriage Certificate *

Cancelof
Social Security Card*

Cancelof
Domestic Partnership Registration Certificate*

Cancelof
Certification Letter from the City Health Benefits Program*

Cancelof

Dependent Questions
Would you like to add dependents on for coverage?*

YesNo
How many would you like to add?

Life Insurance Benefits to Be Paid To: (One Required)
Survivor 1
Name*

First NameMiddle NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Survivor2
Survivor 2
Name

First NameMiddle NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Survivor3
Survivor 3
Name

First NameMiddle NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Survivor4
Survivor 4
Name

First NameMiddle NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Survivor5
Survivor 5
Name

First NameMiddle NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Acknowledgement of Change and Signature
I attest that the information contained herein is true and complete and authorize the disclosure of such information as described on this enrollment form.
Signature*

Clear
Date*

MonthDayYear
Date
Please state any comments or concerns you may have here:

0/250
Should be Empty: