Iron Road Dependent Supplemental Plan Application

Iron Road Dependent Supplemental Plan Application

2025 Application for Enrollment | Open Enrollment Nov 1 to Dec 18.
This plan is an optional supplemental plan and is not the dependent’s primary insurance plan. Once enrolled, your dependents are required to say in the plan for 12 months. They may leave the plan during open enrollment, after 12 months. The filing limit for all claims is one year from the date the primary insurance paid the claim. If you had previously been enrolled in the DSP and cancelled it (voluntarily or due to non-payment), you can re-enroll three years from the date of your cancelation.
Who can apply for the DSP?

The DSP is for dependents of active employees who are currently enrolled in the Iron Road Challenger Plan. The Plan is for dependents who are on the CHCB or MMCP.

What happens after I submit in my application?

Once we receive your application and enroll your dependents in the DSP, you will receive a confirmation letter, your member ID number with Iron Road will be your 18+ dependents ID number to register online with. Dependents under age of 18 will be on the members profile online, And will be able to check the payment status of the EOB's that have been submitted. Please Note: A completed application does not guarantee eligibility.

How do I pay my premium?

The DSP premium is paid monthly via payroll deduction. By signing this application, you agree to allow your employer to deduct your premium and forward it to Iron Road. The premium for the CHCB plan is $215 per month and $105 per month for the MMCP plan.

PLEASE NOTE: You must select the plan that corresponds to the plan your dependents are enrolled in. Selecting the wrong plan (MMCP or CHCB) may result in termination.

How do I file a claim?

The DSP covers allowable expenses, for your dependents, after all other insurance plans have paid, up to the plan limits.
- Once other plans have paid, you will receive an Explanation of Benefits (EOB).
- Submit all EOB’s to Iron Road online while logged in to members profile at my.ironroad.com or via fax, email or mail.
- Once your claim has been reviewed, Iron Road will pay you directly for the allowable expenses.
- Claims are paid within 30 days.
- You can check the status of a claim online at my.ironroad.com using the dependent’s Member ID number.
- Fax claims to 801-595-4399, email them to help@ironroad.com, or mail to PO BOX 161020 Salt Lake City, UT 84116 - Attn DSP.
What if I have questions?

We are always happy to hear from you and to answer any questions you have. You can contact Iron Road Member Services at 800-547-0421, Monday through Friday from 7:30 a.m. to 3:30 p.m., MST. You can also email us at help@ironroad.com.

Iron Road Member Information
MMCPCHCB
Number of dependents you plan to enroll*
Max of eight. For more than eight, contact Member Services.
Please provide information about the current Iron Road (employee) member.*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Phone Number*

Area CodePhone Number
Email*
example@example.com
Iron Road Member ID Number*
UPRR Employee ID Number*

Dependent One

First NameLast Name
Dependent Date of Birth

MonthDayYear
Gender
Relationship to Member
Daughter, Son, Spouse
Is dependent covered under any other insurance company?
Name of insurance company
Dependent Two

First NameLast Name
Dependent Date of Birth

MonthDayYear
Gender
Relationship to Member
Daughter, Son, Spouse
Is dependent covered under any other insurance company?
Name of insurance company
Dependent Three

First NameLast Name
Dependent Date of Birth

MonthDayYear
Gender
Relationship to Member
Daughter, Son, Spouse
Is dependent covered under any other insurance company?
Name of insurance company
Dependent Four

First NameLast Name
Dependent Date of Birth

MonthDayYear
Gender
Relationship to Member
Daughter, Son, Spouse
Is dependent covered under any other insurance company?
Name of insurance company
Dependent Five

First NameLast Name
Dependent Date of Birth

MonthDayYear
Gender
Relationship to Member
Daughter, Son, Spouse
Is dependent covered under any other insurance company?
Name of insurance company
Dependent Six

First NameLast Name
Dependent Date of Birth

MonthDayYear
Gender
Relationship to Member
Daughter, Son, Spouse
Is dependent covered under any other insurance company?
Name of insurance company
Dependent Seven

First NameLast Name
Dependent Date of Birth

MonthDayYear
Gender
Relationship to Member
Daughter, Son, Spouse
Is dependent covered under any other insurance company?
Name of insurance company
Dependent Eight

First NameLast Name
Dependent Date of Birth

MonthDayYear
Gender
Relationship to Member
Daughter, Son, Spouse
Is dependent covered under any other insurance company?
Name of insurance company

Your Agreement & Signature

By my signature below, I represent that the information given on this form is correct to the best of my knowledge and I agree to the following:

I hereby authorize my employer to deduct the required contributions for the (circle one) Iron Road Healthcare CHCB Dependent Supplemental Plan ($195 per month) or Iron Road MMCP Dependent Supplemental Plan ($105 per month) from my wages and to forward the contributions to Iron Road. I agree to comply with the rules and regulations of the supplemental plan I have chosen, and understand and agree that it is my responsibility to advise Iron Road if (1) my dependents’ coverage under their health insurance or coverage is terminated or changes from the coverage listed in Step 1 of this form; (2) I have new dependents; and/or (3) persons previously reported as my dependents are no longer my dependents. If my dependents’ primary coverage changes or terminates and Iron Road is not advised, I understand that Iron Road will not refund my contributions. If there are no payroll deductions, I understand that I must make the required contributions directly to Iron Road and that if I do not do so, my coverage will be canceled. I understand that if this coverage is canceled, I must wait until the next open enrollment after three years have passed since such cancellation before I can re-enroll in the Plan. I understand that this Plan requires me to be enrolled (1) from my initial date of enrollment until the following December 31; and (2) in subsequent years, for a 12-month Plan Year, beginning January 1st and ending the following December 31. I also understand that I will automatically be re-enrolled for subsequent Plan Years unless I notify Iron Road in writing prior to December 1st before the beginning of the Plan Year.
Iron Road Member Signature*
Today's Date*

MonthDayYear
Date
Please verify that you are human*
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