• 313 Healthcare Enrollment Questionnaire

    **Please note: if you are adding your spouse or dependent children to your healthcare plan, you will need to upload appropriate documentation (marriage/birth certificates). Without these documents, they will not be added to your plan!**
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  • Marital Status*
  • Plan Participation Status*
  • Eligibility Status*
  • Do you need to update information for your spouse?*
  • Do you need to update information for your dependent children?*
  • Do you need to update your beneficiaries?*

  • Spouse Information

    **If you are adding your spouse to your healthcare plan, you will need to upload his/her marriage and birth certificate**
  • Spouse's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marriage Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is your spouse employed?

  • Dependent Children

    **If you are adding dependent children to your healthcare plan, you will need to upload their birth certificate**
  • 1st Child's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is Your 1st Child Permanently Disabled?
  • 2nd Child's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is Your 2nd Child Permanently Disabled?
  • 3rd Child's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is Your 3rd Child Permanently Disabled?
  • 4th Child's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is Your 4th Child Permanently Disabled?
  • 5th Child's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is Your 5th Child Permanently Disabled?
  • 6th Child's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is Your 6th Child Permanently Disabled?

  • Other Insurance Coverage

  • Do you or your spouse have any other insurance coverage for yourselves or your children?
  • Effective Date of Policy
     - -
    2 digit month, 2 digit day, 4 digit year

  • Beneficiary Information

  • Upload Dependent Documentation

    If you are adding your spouse or dependent children to your healthcare plan, please upload the appropriate documentation (marriage/birth certificates).
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  • Employee Signature

  • I certify all information on this form is true and correct. I understand that my beneficiary designation will apply to the Health and Welfare Fund only. For other funds, please request and complete a separate beneficiary form. This information on this form supersedes all previous information and beneficiary designations. 

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: