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 Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
Date
Social Security Number *
Phone Number *

Area Code Phone Number
Gender *
Marital Status *

Single Married Divorced Widowed
Plan Participation Status *

Active Retired Disabled
Eligibility Status *

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

Yes No
Do you need to update information for your dependent children? *

Yes No
Do you need to update your beneficiaries? *

Yes No
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 Name Last Name
Spouse's Date of Birth

Month Day Year
Date
Spouse's Social Security Number
Marriage Date

Month Day Year
Date
Is your spouse employed?

Yes No
Name of Employer
Address of Employer

Street Address

Street Address Line 2

City State / 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 Name Last Name
1st Child's Date of Birth

Month Day Year
Date
1st Child's Social Security Number
1st Child's Gender
Is Your 1st Child Permanently Disabled?

Yes No
2nd Child's Name

First Name Last Name
2nd Child's Date of Birth

Month Day Year
Date
2nd Child's Social Security Number
2nd Child's Gender
Is Your 2nd Child Permanently Disabled?

Yes No
3rd Child's Name

First Name Last Name
3rd Child's Date of Birth

Month Day Year
Date
3rd Child's Social Security Number
3rd Child's Gender
Is Your 3rd Child Permanently Disabled?

Yes No
4th Child's Name

First Name Last Name
4th Child's Date of Birth

Month Day Year
Date
4th Child's Social Security Number
4th Child's Gender
Is Your 4th Child Permanently Disabled?

Yes No
5th Child's Name

First Name Last Name
5th Child's Date of Birth

Month Day Year
Date
5th Child's Social Security Number
5th Child's Gender
Is Your 5th Child Permanently Disabled?

Yes No
6th Child's Name

First Name Last Name
6th Child's Date of Birth

Month Day Year
Date
6th Child's Social Security Number
6th Child's Gender
Is Your 6th Child Permanently Disabled?

Yes No
Other Insurance Coverage
Do you or your spouse have any other insurance coverage for yourselves or your children?

Yes No
Name of Carrier
Policy Number
Address of Carrier

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Effective Date of Policy

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

First Name Last Name
1st Beneficiary's Address

Street Address

Street Address Line 2

City State / Province

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

First Name Last Name
2nd Beneficiary's Address

Street Address

Street Address Line 2

City State / Province

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

First Name Last Name
3rd Beneficiary's Address

Street Address

Street Address Line 2

City State / Province

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

First Name Last Name
4th Beneficiary's Address

Street Address

Street Address Line 2

City State / 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

Cancel of
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

Month Day Year
Should be Empty:

313 Healthcare Enrollment Questionnaire

Spouse Information

Dependent Children

Other Insurance Coverage

Beneficiary Information

Upload Dependent Documentation

Employee Signature