ENROLLMENT FORMPlease complete this form in its entirety, front and back and return it in the enclosed envelope. The information requested below is very important as it provides the Plan office with current information about you and your dependents. Please only list those dependents who meet the definition of an Eligible Dependent, as that term is defined in your Summary Plan Description. This form also allows you to designate a beneficiary for the purpose of receiving benefits from the Fund upon your death. Please sign and date the form.
In order to enroll dependents below for coverage under the Plan, please provide copies of marriage certificate(s) and birth certificate(s) (For Children only). The Plan office will not verify dependent coverage to providers or process claims on their behalf without this documentation. If you have previously provided this information for each of the dependents you list below, it is not necessary for you to submit it again.