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Health & Welfare Fund Application

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Personal Information - Step 1 of 3

Personal Information

Please select your purpose for filling out this application *

New Enrollee
Notification of Change
Required Yearly Update

Reason for change

Please Choose *

Plan A
Plan B

Anyone not eligible for Plan A will automatically be enrolled in plan B.

More information on Plan A
More information on Plan B

Name *

First

Middle

Last

Address *

Address Line 1

City

State

Zip Code

Social Security Number *

Date of Birth *

Gender *

Male
Female

Please upload a copy of your birth certificate

Drag & Drop Files, Choose Files to Upload

Please upload a copy of your driver's license

Drag & Drop Files, Choose Files to Upload

Email *

Phone

Marital Status *

Single
Married
Widowed
Divorced
Legally Separated

Please upload a copy of your marriage license

Drag & Drop Files, Choose Files to Upload

Please upload a copy of your divorce decree

Drag & Drop Files, Choose Files to Upload

Are you or any of your dependants covered under any other Group Medical or Dental Plan or Medicare? *

If yes, how many people are currently covered in your family under the additional plan?

Name *

First

Middle

Last

Name *

First

Middle

Last

Name *

First

Middle

Last

Name *

First

Middle

Last

Name *

First

Middle

Last

How many other Group Medical and/or Dental Plan(s) do you currently have?

Plan A Coverage Only

Group Medical or Dental Plan Information

First Group Medical or Dental Plan Information

Name of other Group Medical or Dental Plan

Address

Address Line 1

City

State

Zip Code

Effective Date of other Group Plan or Dental Plan

Group Number

Second Group Medical or Dental Plan Information

Name of your second Group Medical or Dental Plan

Address

Address Line 1

City

State

Zip Code

Effective Date of other Group Plan or Dental Plan

Group Number

Third Group Medical or Dental Plan Information

Name of your third Group Medical or Dental Plan

Address

Address Line 1

City

State

Zip Code

Effective Date of other Group Plan or Dental Plan

Group Number

Fourth Group Medical or Dental Plan Information

Name of your fourth Group Medical or Dental Plan

Address

Address Line 1

City

State

Zip Code

Effective Date of other Group Plan or Dental Plan

Group Number

* I herby designate (name of Beneficiary listed below), as the beneficiary whom shall be paid any benefit to which I may be entitled at the time of my death. This is in lieu of any former such designation made by me.

Name of Beneficiary *

First

Middle

Last

Relationship of Beneficiary *

Employee's Signature *

Clear Signature

Witness Signature

Clear Signature

Dependent Coverage

Do you have eligible Dependants? *

How many dependents do you have?

Dependent's Information

First Dependent's Information

Dependent's Name

First

Middle

Last

Social Security Number

Date of birth

Gender

Male
Female

Please upload a copy of your dependent's birth certificate

Drag & Drop Files, Choose Files to Upload

Relationship to employee

Address if different from employee

Address Line 1

City

State

Zip Code

Second Dependent's Information

Second Dependent's Name

First

Middle

Last

Social Security Number

Date of birth

Gender

Male
Female

Please upload a copy of your dependent's birth certificate

Drag & Drop Files, Choose Files to Upload

Relationship to employee

Address if different from employee

Address Line 1

City

State

Zip Code

Third Dependent's Information

Third Dependent's Name

First

Middle

Last

Social Security Number

Date of birth

Gender

Male
Female

Please upload a copy of your dependent's birth certificate

Drag & Drop Files, Choose Files to Upload

Relationship to employee

Address if different from employee

Address Line 1

City

State

Zip Code

Forth Dependent's Information

Fourth Dependent's Name

First

Middle

Last

Social Security Number

Date of birth

Gender

Male
Female

Please upload a copy of your dependent's birth certificate

Drag & Drop Files, Choose Files to Upload

Relationship to employee

Address if different from employee

Address Line 1

City

State

Zip Code

Fifth Dependent's Information

Fifth Dependent's Name

First

Middle

Last

Social Security Number

Date of birth

Gender

Male
Female

Please upload a copy of your dependent's birth certificate

Drag & Drop Files, Choose Files to Upload

Relationship to employee

Address if different from employee

Address Line 1

City

State

Zip Code

I certify that the information above is true, factual and complete. I certify that all the dependents I have listed above are eligible dependents under the terms of the plan and are eligible to be claimed by me as a dependent for Federal Income Tax purposes. I understand that falsification of this document may result in loss of coverage. *

I agree

Signature *

Clear Signature

Today's Date *

I authorize the disclosure of PHI to (choose one): *

All claims and other documents related to my healthcare
Specific claim(s) data
Other

Please provide Date of Service and Provider Name or other information specifically identifying the claim(s):

Other:

Entity authorized to disclose PHI: Operating Engineers Local 112 Health and Welfare and their designated business associates.

Would you like to authorize anyone else to receive PHI? *

This disclosure of PHI is made at the request of the individual unless otherwise noted here.

How many people would you like to authorize to receive PHI? *

First Dependent's Information

Name

First

Middle

Last

Date of Birth

Address

Address Line 1

City

State

Zip Code

Second Dependent's Information

Name

First

Middle

Last

Date of Birth

Address

Address Line 1

City

State

Zip Code

Third Dependent's Information

Name

First

Middle

Last

Date of Birth

Address

Address Line 1

City

State

Zip Code

Fourth Dependent's Information

Name

First

Middle

Last

Date of Birth

Address

Address Line 1

City

State

Zip Code

Fifth Dependent's Information

Name

First

Middle

Last

Date of Birth

Address

Address Line 1

City

State

Zip Code

Expiration Details

The authorization is valid for one year beyond termination of the individual’s eligibility with the Fund
This authorization expires on (please fill out date below)
This authorization expires in the event of (please describe an applicable expiration event below)

Date of expiration

Please describe an applicable expiration event:

1. I understand that I may revoke this authorization at any time by notifying the Fund Privacy Officer in writing. Details on the conditions of revocation may be found in the Notice of Privacy Practices, which is available upon request. In the case of revocation, I understand that changes will not be considered applicable to any action taken before receipt of the revocation. *

I agree

2. I understand that the payment for my healthcare benefits will not be affected if I do not sign this form unless the Fund specifically requires this authorization to determine eligibility or enrollment information, or requires this document for use in underwriting or risk determination. *

I agree

3. I understand that I may request to review the information described on this form, and that I may request a copy of this form after I sign it. *

I agree

I, the undersigned, have read the above information and hereby authorize the use or disclosure of my individually identifiable health information for the purpose described above. I understand this authorization is voluntary. I understand if the person/entity authorized to receive the information is not bound by HIPAA, the released information may not longer be protected by federal privacy regulations. Furthermore, I release the Fund from any liability for any release made as a result of this authorization. *

I agree

Signature

Clear Signature

Today's Date (copy) *