Enrollment Form

Last Name: *

Enter your entire last name

First Name: *

Enter your entire first name

Middle Name: *

Enter your entire middle name

Date of Birth: *

Gender: *

Male

Female

Street Address: *

City: *

State: *

Please enter the entire State Name

Zip Code: *

+ 4:

Telephone Number: *

Include Area Code but not dashes

Current Local Union Number: *

Union City: *

Union State: *

Continuous Member since: *

Participant Signature: *

Please enter your complete first and last names

Today's Date: *

Marriage Date:

Widowed Date:

Separation Date:

Divorce Date:

Name - Dependent 1:

SSN for Dep. 1:

DOB 1:

Relationship 1:

Other Ins. 1:

Yes

Name - Dependent 2:

SSN for Dep. 2:

DOB 2:

Relationship 2:

Other Ins. 2:

Yes

Name - Dependent 3:

SSN for Dep. 3:

DOB 3:

Relationship 3:

Other Ins. 3:

Yes

Name - Dependent 4:

SSN for Dep. 4:

DOB 4:

Relationship 4:

Other Ins. 4:

Yes

Medicare?:

Yes

Other Insurance/Medicare Termination Date:

Coverage Owner:

Owner's SSN:

Owner's DOB:

dependents?:

Yes

Family Members Covered:

Coverage Types:

Medical

Dental

Vision

Other

Other:

Coverage 1:

Term Date 1:

Coverage 2:

Term Date 2:

Coverage 3:

Term Date 3:

Insurance Carrier 1:

Plan Effective Date:

Group/Plan Number:

Primary Insured's Name:

Insured's Number:

Insurance Carrier 2:

Plan Effective Date:

Group/Plan Number:

Primary Insured's Name:

Insured's Number:

Participant's Signature:

Today's Date:

Spouse's Signature:

Today's Date:

Beneficiary Name:

Relationship:

Address:

Phone #:

Include Area Code

Contigent Beneficiary Name:

Relationship:

Address:

Phone:

Additional Beneficiaries:

Yes

Participant Signature:

Date:

Beneficiary Name:

Name of Pension Plan Beneficiary.

SSN: Do not use dashes

Social Security Number of Pension Plan Beneficiary

Relationship:

Relationship of Pension Plan Beneficiary to Plan Owner

Address:

Address for Pension Plan Beneficiary

Phone #:

Participant Signature:

Plan owner signature for Pension Plan Section.

Date:

Section 2A - Must be completed for Welfare Coverage

Section 1 - Must be completed in full (Member information only in Section 1)

2 letter abbreviation - e.g. IL

WELFARE & PENSION FUNDS

It is fraudulent to fill out this form with information you know to be false or knowingly omit important facts. Criminal and/or Civil penalties can result from such an act. If any of the above information is untrue, I agree to reimburse the Fox Valley Laborers Health and Welfare Fund for any money it was induced to pay as a result of the information I provided. Receipt of this Form is not a guarantee of eligibility. Failure to return this form and required documents may result in a delay in claim processing.

Choose one:

Print Names of all Dependents Below - Do Not repeat yourself

You must also send the following documentation to the Welfare office:

For Spouse - Send a copy of the marriage certificate, birth certificate and social security card.

For Dependent Children - Send a copy of the birth certificate and social security card.

Fill out the one Date below that matches your status above.

For each dependent you must fill out the following information:

2. Social Security Number (without dashes)

3. Date of Birth

4. Relationship

5. Whether they have other Insurance or not

Additional Dependents will need to be listed on a second form and emailed in separately.

Is any member of your family covered by any other insurance plan or eligible for

If No, enter the termination date of the other coverage below (if applicable), then sign and date right above Section 2B.

Section 2B - Welfare Plan Beneficiary Designation

If Yes, complete the rest of Section 2A and then sign and date right above Section 2B below.

Does the plan cover your

If Yes, list all of the family members covered in the space below.

Select all of the types of coverage provided by the plan(s).

If any of the above coverage has terminated, select the type of coverage and its termination date.

Name & Address of other insurance carrier(s):

I hereby designate the following-named beneficiary(ies) as provided in the welfare plan:

(If you name more than 1 person, benefits will be shared equally)

Section 3 - Pension Plan Beneficiary Designation

If none of the above-named beneficiary(ies) are living at the time of my death, I designate the following-named contigent beneficiary(ies):

(Benefits will be shared equally unless otherwise indicated)

If you are married and wish to designate any beneficiary(ies) other than your spouse, or your spouse shares in the Pension Benefits, your spouse must consent in writing to such designation and the consent must be witnessed by a Notary Public. To do this, Submit this form (by clicking on the button below) and then open and print the Enrollment Form PDF file listed on the Forms web page. You will then need to fill out Section 3 on that form, get it Notarized, and deliver it to the Pension office.

Warning!: You must click the Submit button to finalize this form and submit it to the office for processing.

Health, Welfare and Pension Funds

Counter