313 Healthcare Enrollment Questionnaire

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!**
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check if address is new
Date of Birth*

MonthDayYear
Date
Social Security Number*
Phone Number*

Area CodePhone Number
Gender*
Marital Status*

SingleMarriedDivorcedWidowed
Plan Participation Status*

ActiveRetiredDisabled
Eligibility Status*

Non-Medicare EligibleMedicare Eligible
Do you need to update information for your spouse?*

YesNo
Do you need to update information for your dependent children?*

YesNo
Do you need to update your beneficiaries?*

YesNo
Spouse Information

**If you are adding your spouse to your healthcare plan, you will need to upload his/her marriage and birth certificate**
Spouse's Name

First NameLast Name
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Social Security Number
Marriage Date

MonthDayYear
Date
Is your spouse employed?

YesNo
Name of Employer
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dependent Children

**If you are adding dependent children to your healthcare plan, you will need to upload their birth certificate**
How many dependent children do you have?
1st Child's Name

First NameLast Name
1st Child's Date of Birth

MonthDayYear
Date
1st Child's Social Security Number
1st Child's Gender
Is Your 1st Child Permanently Disabled?

YesNo
2nd Child's Name

First NameLast Name
2nd Child's Date of Birth

MonthDayYear
Date
2nd Child's Social Security Number
2nd Child's Gender
Is Your 2nd Child Permanently Disabled?

YesNo
3rd Child's Name

First NameLast Name
3rd Child's Date of Birth

MonthDayYear
Date
3rd Child's Social Security Number
3rd Child's Gender
Is Your 3rd Child Permanently Disabled?

YesNo
4th Child's Name

First NameLast Name
4th Child's Date of Birth

MonthDayYear
Date
4th Child's Social Security Number
4th Child's Gender
Is Your 4th Child Permanently Disabled?

YesNo
5th Child's Name

First NameLast Name
5th Child's Date of Birth

MonthDayYear
Date
5th Child's Social Security Number
5th Child's Gender
Is Your 5th Child Permanently Disabled?

YesNo
6th Child's Name

First NameLast Name
6th Child's Date of Birth

MonthDayYear
Date
6th Child's Social Security Number
6th Child's Gender
Is Your 6th Child Permanently Disabled?

YesNo
Other Insurance Coverage
Do you or your spouse have any other insurance coverage for yourselves or your children?

YesNo
Name of Carrier
Policy Number
Address of Carrier

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Effective Date of Policy

MonthDayYear
Date
Beneficiary Information
How many beneficiaries would you like to designate?
1st Beneficiary's Name

First NameLast Name
1st Beneficiary's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1st Beneficiary's Social Security Number
Relationship to 1st Beneficiary
2nd Beneficiary's Name

First NameLast Name
2nd Beneficiary's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Beneficiary's Social Security Number
Relationship to 2nd Beneficiary
3rd Beneficiary's Name

First NameLast Name
3rd Beneficiary's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3rd Beneficiary's Social Security Number
Relationship to 3rd Beneficiary
4th Beneficiary's Name

First NameLast Name
4th Beneficiary's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4th Beneficiary's Social Security Number
Relationship to 4th Beneficiary
Upload Dependent Documentation

If you are adding your spouse or dependent children to your healthcare plan, please upload the appropriate documentation (marriage/birth certificates).
Without these documents, they will not be added to your plan!

Browse Files

Cancelof
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.
Please sign

Clear
Today's Date

MonthDayYear
Should be Empty:

313 Healthcare Enrollment Questionnaire

Spouse Information

Dependent Children

Other Insurance Coverage

Beneficiary Information

Upload Dependent Documentation

Employee Signature