LACCU PARTICIPANT DATA FORM

Los Angeles Coalition of County Unions
Retiree Medical Trust

Administered By: Benefit Programs Administration
Telephone: (833) 504-3964 | Facsimile: (562) 463-5894
E-mail: laccurmt@bpabenefits.com
PARTICIPANT DATA FORM
Plan Participant Name:
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone #:
Format: (000) 000-0000.
Date of Birth:

MonthDayYear
Date
Social Security #:
Non-Work Email Address:
example@example.com
Participating Employer / Bargaining Unit:
Date of Hire:

MonthDayYear
Date
Date of Termination:

MonthDayYear
Date
Spouse / Domestic Partner:
Date of Birth:

MonthDayYear
Date
Date of Marriage:

MonthDayYear
Date
Dependent Information:
Dependent Name:
Relationship:
Date of Birth:

MonthDayYear
Date
Dependent Name:
Relationship:
Date of Birth:

MonthDayYear
Date
Dependent Name:
Relationship:
Date of Birth:

MonthDayYear
Date
I certify under penalty of perjury that the foregoing is true and correct. I understand that the Trust may pursue legal and equitable remedies and/or recoupment of benefits against me for any false, fraudulent or misleading information provided now or in other communications with the Trust Office.
Participant's Signature
Date

MonthDayYear
Should be Empty:

Los Angeles Coalition of County UnionsRetiree Medical Trust