• 313 Healthcare Enrollment Questionnaire

    **Please note: if you are adding your spouse or dependent children to your healthcare plan, you will need to upload appropriate documentation (marriage/birth certificates). Without these documents, they will not be added to your plan!**
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  • Spouse Information

    **If you are adding your spouse to your healthcare plan, you will need to upload his/her marriage and birth certificate**
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  • Dependent Children

    **If you are adding dependent children to your healthcare plan, you will need to upload their birth certificate**
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  • Other Insurance Coverage

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  • Beneficiary Information

  • Upload Dependent Documentation

    If you are adding your spouse or dependent children to your healthcare plan, please upload the appropriate documentation (marriage/birth certificates).
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  • Employee Signature

  • I certify all information on this form is true and correct. I understand that my beneficiary designation will apply to the Health and Welfare Fund only. For other funds, please request and complete a separate beneficiary form. This information on this form supersedes all previous information and beneficiary designations. 

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