Southeastern Iron Workers Health Care Plan by Southern Benefit Administrators, Inc.
Mailing Address: Telephone: (615) 859-0131 Street Address:
P. O. Box 1449 Toll Free: (800) 831 -4914 2001 Caldwell Drive
Goodlettsville, TN 37070-1449 Fax: (615) 859-6792 Goodlettsville, TN 37072-2328

ENROLLMENT FORM
Please 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.

Participant Name
Your answer
Date of Birth
Please email or fax (404-505-1107) proof of birth to the Union Hall for processing.
Your answer
Sex
Address, City, State and Zip
Your answer
Social Security #
Please email or fax(404-505-1107) this document to the Union Hall for processing.
Your answer
Local Union No.
Your answer
Participant's Email
Your answer
Phone Number
Your answer
Spouse Name
Your answer
Spouse Date of Birth
Please email for fax (404-505-1107) proof of birth to the Union Hall for processing.
Your answer
Sex of Spouse
Date of Marriage
Please email of fax (404-505-1107) this document to the Union Hall for processing.
Your answer
Spouse Social Security #
Please email or fax (404-505-1107) this document to the Union Hall for processing.
Your answer
Spouse Email
Your answer
Spouse Phone Number
Your answer
Dependent Children First and Last Name: *
Your answer
Dependent Social Security #
Please email or fax (404-505-1107) this document to the Union Hall for processing.
Your answer
Dependent Date of Birth
Please email or Fax (404-505-1107) this document to the Union Hall for processing.
Your answer
Additional Dependents : Enter same information *
Your answer
DESIGNATION OF BENEFICIARY *
Your answer
Beneficiary Mailing Address *
Your answer
Contingent Beneficiary Full Name *
Your answer
Contingent Beneficiary Mailing Address *
Your answer
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