• Heating, Piping, and Refrigeration Medical Fund

    Physical Address: 8700 Ashwood Dr. Suite 150, Capitol Heights, MD 20743 • Mailing Address: 8700 Ashwood Dr. Suite 150, Capitol Heights, MD 20743
    Phone: (410) 444-3756 or (800) 618-2879 • Fax: (240) 303-2484• Website: HPRBenefitFunds.com

    Administered by Welfare & Pension Administration Service, Inc.

    ENROLLMENT FORM

  • Section I – General Information

  • Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Marital Status*
  • Date of Marriage*
     - -

  • 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.
  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Date of Birth*
     - -
  • Gender*
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  • Declaration of Health Insurance

    The form below is intended to solicit information concerning other Medical Benefits which may be available to your spouse or dependent children. If that other coverage is Primary to the Fund, having this information on file will help ensure the accurate payment of the claim and also maximize the benefit dollars available from your Health Fund. This information is required to be updated every 12 months. Please complete the form and return it to the Fund Office. Your assistance in this process is appreciated.
  • Other Coverage*
  • Effective Date*
     - -
  • Type of Coverage (check all that apply)*
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  • Do you have any additional coverage not listed?*
  • Effective Date*
     - -
  • Type of Coverage (check all that apply)*
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  • Important: If the other coverage terminates, the Fund requires a copy of the HIPAA notice issued from the other carrier. This notice is required to be mailed upon termination.

  • Date*
     - -
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  • Should be Empty: