HPR Enrollment Form

Section II – Heating, Piping and Refrigeration Medical Fund Enrollment Card
- In order to add a spouse we must have a copy of your marriage certificate and your spouse’s Social Security card.
- In order to add a child, we must have a copy of their State issued birth certificate and their Social Security Card.
- If you are adding a child from a previous marriage or a stepchild, we must have a copy of their State issued birth certificate and a copy of their Social Security Card.
How many dependents, including spouse, are your enrolling?*
If only enrolling yourself, select 0

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 14
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof
Over 7 dependents

Yes

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form Address 13
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 12
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 11
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 10
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 9
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 8
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
Dependent State*
Zip Code*
Dependent Form 7
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation*

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 6
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 5
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 4
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 3
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Dependent Street Address*
City*
State*
Zip Code*
Dependent Form 2
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Dependent Name*

First NameMiddle NameLast Name
Same as Member Address
Separator
Dependent Street Address*
City*
Dependent State*
Zip Code*
Dependent Form 1
Social Security Number*
Relationship*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Upload Copies of Supporting Documentation*

Marriage Certificate, Birth Certificate, Social Security Card, etc.
Cancelof

Heating, Piping, and Refrigeration Medical Fund