Michigan Laborers' Health Care Fund
HEALTH CARE (BCBSM) ENROLLMENT FORM
General Employee Information
Name
*
First Name
Middle Name
Last Name
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Current Marital Status
*
Single
Married
Divorced
Date of Marriage
*
-
Month
-
Day
Year
Date
Local Union Number
*
Spouse/Dependent Information
The Fund requires the following documentation for your spouse and each dependent you are enrolling:
a copy of the marriage certificate; and or
a copy of the birth certificate or proof of legal guardianship for each child
How many dependents, including your spouse, are you enrolling?
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
If only enrolling yourself, select 0
Name
*
First Name
Middle Name
Last Name
Form Name 1
Spacer
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 1
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 2
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 2
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 3
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 3
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 4
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 4
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 5
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 5
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 6
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 6
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 7
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 7
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 8
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 8
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 9
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 9
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Name
*
First Name
Middle Name
Last Name
Form Name 10
Same as Member Address
Street Address
*
City
*
State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
*
Form Address 10
Social Security Number
*
Relationship
*
Please Select
Spouse
Child
Stepchild
Foster Child
Adopted Child
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Upload Required Documentation
*
Browse Files
Drag and drop files here
Choose a file
Marriage Certificate (Spouse) or Birth Certificate/Proof of Legal Guardianship (Dependent)
Cancel
of
Participant Signature
*
Date
-
Month
-
Day
Year
Fund ID
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