Fillable TWU LOCAL 100 VISION BENEFITS ENROLLMENT/CHANGE FORM

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TWU LOCAL 100 VISION BENEFITS ENROLLMENT/CHANGE FORM

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Last Name Address
First Name City
Middle Name State Zip Code
Contact Phone BSC # Date Appointed
D.O.B Email Address
TWU LOCAL 100
VISION BENEFITS ENROLLMENT/CHANGE FORM
INCOMPLETE FORMS WILL NOT BE PROCESSED
MEMBER INFORMATION mNew Enrollment mChange
®
DEPENDENTS INFORMATION: Spouse, Domestic Partner & Unmarried dependent Children. Dependent eligibility is governed
by your group’s contract. Dependents between 19 and 23 years of age covered only if enrolled in college full-time.
TWU Local 100 Eective Date m Termination
Signature Date
Last Name
First Name
D.O.B.
GENDER mMale mFemale
RELATIONSHIP mSpouse/D.P. mChild
If student, please provide proof of enrollment:
Name of School
I.D. No.
Last Name
First Name
D.O.B.
GENDER mMale mFemale
RELATIONSHIP mSpouse/D.P. mChild
If student, please provide proof of enrollment:
Name of School
I.D. No.
INTERNAL
USE
520 8th Avenue, 9th Floor
New York, NY 10018
Phone (855) 653-0584
mAdd mRemove
mAdd mRemove
GENDER mMale mFemale
MARITAL STATUS mSingle mMarried mDomestic Partnership mDivorced/Widowed
In order for TWU-Local 100 to complete the processing of your benefits, you must provide us with copies of the following documents:
• Marriage certificate for spouse
• Birth certificate for all dependents
• Social Security cards for all dependents
• Adoption/Legal Guardianship papers for dependent children
Last Name
First Name
D.O.B.
GENDER mMale mFemale
RELATIONSHIP mSpouse/D.P. mChild
If student, please provide proof of enrollment:
Name of School
I.D. No.
Last Name
First Name
D.O.B.
GENDER mMale mFemale
RELATIONSHIP mSpouse/D.P. mChild
If student, please provide proof of enrollment:
Name of School
I.D. No.
mAdd mRemove
mAdd mRemove
Any person who knowingly and with intent to defraud any statement of claim containing any materially false information,
or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act,
which is a crime, and shall also be subject to a civil penalty. Vision benefits will be eective 90 days after hire date.
I agree to be liable for any claims presented and paid as a result of such fraudulent act.
FAX DOCUMENTS TO: TWU LOCAL 100 MEMBER SERVICES 347.643.8063
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TWU LOCAL 100 VISION BENEFITS ENROLLMENTCHANGE FORM

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Completed 21 June 2022

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