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National Roofers Union & Employers Joint Health & (National Roofers Union & Employers Joint Health & Welfare Fund)

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Complete this form to update the Fund Ofce, Wilson-McShane Corporation, of any changes regarding your dependents
and their insurance coverage. When adding or removing dependents you must submit this form along with the required
documentation listed on the reverse side of this form under “Required Documentation”. When you rst become eligible,
you must complete this form to enroll your dependents in coverage from the Plan.
FAMILY UPDATE FORM
Do you have other insurance? Yes No (If yes, please attach copy of the front and back of the other insurance I.D. card)
Name: Social Security Number:
Date of Birth: Phone Number:
Address: Marital Status: Single Married Divorced
Date of Marriage or Divorce:______________________________________
Name: Social Security Number:
Date of Birth: Phone Number:
Spouse’s Employer Name: Employer’s Address:
Employer’s Phone Number:
Does your spouse have other Group Medical Coverage?
Yes No If yes, is the coverage type: Single or Family
Medical Insurance Carrier Name: Insurance Carrier Phone Number:
Insurance Carrier Address: Group Contract Number:
Effective Date:___________________ Term Date:____________________
Does coverage include Dental? Yes No Does coverage include Vision? Yes No
Insured’s Data
Spouse’s Data
Spouse’s Insurance Data (you must include a copy of the front and back of the I.D. card for the other coverage)
Dependent Child Information:
Make sure you ll out ALL the below information for each Dependent that is eligible for coverage from the Plan. It is extremely important
that you list each of your Dependent children that is under the age of 26. If you have more than six eligible Dependents, please attach
a separate sheet of paper with information regarding those additional Dependents and list your name at the top of that sheet of paper.
Dependent’s Name Relationship Date of Social Security Sex Do they Employer/Other Insurance
Birth Number have other
(you must include a photocopy
insurance? of the front and back of the
I.D. card for the other coverage)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
over
National Roofers Union & Employers Joint Health & Welfare Fund
3001 Metro Drive - Suite 500 | Bloomington, MN 55425 | 952.854.0795 | 800.622.8780
Medicare Information
Is anyone eligible for the National Roofers Union & Employers Joint Health & Welfare Fund benets also eligible for
Medicare?
□ Yes (Please complete this Medicare Information section below for Medicare eligible person(s))
□ No (Please skip this Medicare Information section below)
Name:_____________________________________ Date of Birth _____ /_____ /_____ Medicare HIC #: _______
Effective Date: Part A: _____ /_____ /_____ Part B: _____ /_____ /_____ Relationship:_____________________
Medicare due to:
□ End-stage renal disease and/or □ disability □ age Effective Date: _____ /_____ /_____
Name:_____________________________________ Date of Birth _____ /_____ /_____ Medicare HIC #: _______
Effective Date: Part A: _____ /_____ /_____ Part B: _____ /_____ /_____ Relationship:_____________________
Medicare due to:
□ End-stage renal disease and/or □ disability □ age Effective Date: _____ /_____ /_____
If you are retired, please indicate retirement date: _____ /_____ /_____
Required Documentation
If you get married, provide the Fund Ofce with:
•A copy of your marriage certicate
•Your spouse’s date of birth
•A copy of your spouse’s medical insurance information, if he or she is covered under another plan
If you add a child, provide the Fund Ofce with:
•The birth date, effective date of adoption or placement for adoption, or the date of your marriage (for stepchildren)
•When you add a stepchild, you must submit a copy of your spouse’s divorce decree to establish if there is other
coverage for that child
•A copy of the birth certicate, adoption papers, court order, or marriage certicate (for stepchildren)
•A copy of your child’s other medical insurance information, if he or she is covered under another plan
•Other information as may be requested by the Fund Ofce in order to demonstrate eligibility
If you get legally separated or divorced, provide the Fund Ofce with:
•A copy of your separation or divorce decree
•A copy of any QDRO
•If you have children for whom you do not have custody, a copy of any QMCSO
If your legally separated or divorced spouse wants to continue coverage, he or she must:
•Contact the Fund Ofce; and
•Enroll for COBRA Continuation Coverage
We are pleased to be of service to you. Please contact this ofce if you have any questions. The following is extremely important in-
formation. Please read this language carefully and then sign and date this Family Update Form and return it to the Fund Ofce.
I hereby certify that all information provided on this Family Update Form is correct to the best of my knowledge. I understand that if this
information changes, it is my responsibility to notify the Fund Ofce immediately. I also understand that I will be required to reimburse
the Plan for any payments made as a result of my failure to notify the Fund Ofce of a change in the information provided on this Family
Update Form. Your Signature will also authorize an institution or physician to release information concerning your enrollment, related
records and medical records to the fund ofce, if needed.
_________________________________________________________________ ___________________________________
Participant’s Signature Date of Signature
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National Roofers Union & Employers Joint Health & (National Roofers Union & Employers Joint Health & Welfare Fund)

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Completed 4 March 2021

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