DEPENDENT CHILDREN/STEPCHILDREN COVERAGE
If any of your dependents are from a previous marriage, born out of wedlock or stepchild(ren), please complete the following:
Name of dependent child(ren):
Are any of the dependent children covered for health benefits under the other biological parent?
Yes No
Effective Date:
/ /
Name of the other biological parent:
Date of Birth:
/ /
Carrier Name:
Policy No:
Subscriber ID#:
If you are divorced, check one of the following:
Divorce decree stipulates the other parent must provide benefits Divorce decree stipulates joint custody Decree does not stipulate special provisions
Name of custodial parent: Mailing Address:
If you have a court order to provide medical coverage for any of the dependent children, please complete the following:
Date of Order: / / Effective Date: / / Child Name:
Custodian Name: Mailing Address:
(Attach copy of divorce decree and/or court order)
MEDICARE COVERAGE
Are you or any of your dependents enrolled in Medicare?
Yes No
(If “YES”, please complete the following):
Name of person eligible for Medicare:
Medicare No.
Reason for Medicare:
Age 65 or older Disability due to _________________________ ESRD / Date Dialysis Treatment Began: ____/____/____
Type of Coverage:
Part A (Hospital) (_____/_____/_____) Part B (Medical) (_____/_____/_____) Part D (Drug) (_____/_____/_____)
(Attach a copy of your Medicare Card)
OTHER HEALTH CARE COVERAGE
Do you or your dependents have any other coverage (i.e., previous employer, TRI-CARE)?
Yes No
(If “YES”, please complete the following)
Subscriber Name:
Subscriber ID #:
Effective Date: / /
Carrier Name:
Policyholder:
Group No:
Coverage Type:
Medical Drug Dental Vision Supplemental Plan Type: Single Family Subscriber & Spouse Retiree
I/We understand that the Fund is relying on this information to determine eligibility for medical benefits for myself and my dependents. I/We understand that it is unlawful for me to
make any statements which I/we know is untrue, false or misleading. I/We declare and affirm in good faith and under perjury under Federal and State laws that the information
provided herein in true and correct to the best of my knowledge and I/We consent to the provisions stated above on this form which I/We have read and fully understand. I/We also
understand that the penalty for committing perjury may be a fine or imprisonment, or both, and may also result in a legal claim against me for recovery or offset of benefits improperly
paid to be or my dependents based on the information provided herein.
Member Signature Date Spouse Signature Date
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