Enrollment Information - Mo-Kan Iron Workers Trust Funds
N CIN G IR ON WORKERS NT ★I BRIDGE, STRUCTU RONNIE L. TRAXLER R ONNIE R ONNIE L. L. T TRAXLER RAXLER CHAIRMAN JOHN T. FULTZ JJSECRETARY OHN OHN T. T. F FULTZ ULTZ mo-kan ironworkers t rust fP unds AnnuAl VerificAtion – J L. N G M. CHAIRMAN CHAIRMAN New Logo SECRETARY SECRETARY IMMY ELSON ATRICK ALLAGHER erification orm JJVICE IMMY L. P ATRICK M. G IMMY L. N NELSON ELSON V P ATRICKF M. GALLAGHER ALLAGHER cInformation oordinAtion of Benefits f orm CHAIRMAN ASSISTANT SECRETARY VICE CHAIRMAN CHAIRMAN VICE R RNA FO MENTAL AND REIN L RA ,O IONAL ASSOCIATIO ★ OF AT ERN ASSISTANT SECRETARY SECRETARY ASSISTANT Please complete ofof this form, sign at the bottom of the last last pagepage and and return. Thiswithin form can Please completethe thefront frontand andback back this form, sign at the bottom of the return 60 be days. If emailed or faxed to the contact information listed at the bottom of this page. it is not received within 60 days prescription benefits will be suspended. Please note: This will not affect your medical claims as Cigna will request their own coordination of benefits information. Participant Information Old Logo IRONWORKERS LOGO.indd 1 Check One: Male Female Last Name First Name Middle Initial Social Security Number ( ) Birth Date (MM/DD/YYYY) Area Code Phone Number 11/8/14 3:01 PM Home Address Apartment Number State Zip Code Email Address City County Check One: Single Married Widowed Separated Divorced: of Divorce (MM/DD/YYYY) Date Are you a policyholder of any other group medical, vision or dental plan other than Medicare? Yes No Are you entitled to Medicare Part A or B? Yes No If yes, submit a copy of your Medicare Card if it hasnot been previously submitted. Is your spouse offered group health coverage through his/her employer (whether they have accept the other coverage or not)? Yes No If yes, did your spouse enroll in that other coverage? Yes No Is your spouse offered group health coverage through his/her employer? Yes No Dependent Information all eligible dependents to be covered. List If you are adding a spouse, please include a copy of your marriage cetificate. County filed copies only. Souvenir copies are not accepted. If you are adding a spouse, please include copy of of your your marriage marriage cetificate. certificate. County County filed filed copies copies only. only. Souvenir copies are If you are adding a spouse, please include a Souvenir copies are not accepted. If please include aa copy copy of your marriage cetificate. County filed copies only. Souvenir copies are not not accepted. accepted. If you you are are adding adding a a spouse, child, please include a copy of their birth certificate. State issued copy only. Souvenir copies are not accepted. you are are adding adding a child, please please include include a copy of of their their birth birth certificate. certificate. State County issued only. copies Souvenir are not accepted. IfIf you you are adding aa child, child, please include aa copy copy of their birth certificate. State or issued copy only.copy Souvenir copies arecopies not accepted. accepted. If State issued copy only. Souvenir are not If either you or your spouse are divorced and you are adding a child or stepchild, submit a copy of the divorce decree and any settlement If either you you or or your your spouse spouse are are divorced divorced and and you you are are adding adding a child or or stepchild, stepchild, submit submit a copy of of the the divorce divorce decree decree and and any any settlement settlement IfIf either either you or your spouse divorced and you are adding aa child child or stepchild, aa copy copy of the divorce decree and any agreement made part of the are decree stating custody and medical responsibility for submit the children. The decree must be signed andsettlement dated by the judge. agreement made part of the decree stating custody and medical responsibility for the children. The decree decree must must be be signed signed and and dated dated by by the the judge. judge. agreement made made part part of of the the decree decree stating stating custody custody and and medical medical responsibility responsibility for for the the children. children. The agreement The decree must be signed and dated by the judge. Note: This form MUST be signed and dated on page 2 to be valid Note: Note: This This form form MUST MUST be be signed signed and and dated dated on on page page 2 2 to to be be valid valid ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •• •• •• •• •• • ••• • ••• • ••• • ••• •• ••• •• ••• •• •• • •• •• ••• •• ••• •• ••• • ••• • ••• • ••• • ••• • ••• • ••• •• ••• •• ••• •• •• • •• •• ••• •• ••• •• ••• • ••• • ••• • ••• • ••• • ••• • ••• •• ••• •• ••• •• •• • •• •• ••• •• ••• •• ••• • ••• • ••• • ••• • ••• • ••• • ••• •• ••• •• ••• •• •• • •• •• ••• • ••• • ••• • ••• •• ••• •• ••• ••• •• ••• •• ••• • ••• • ••• •• ••• •• ••• •• • •• ••• •• ••• • ••• • ••• • ••• •• ••• •• •••Y100 • • • Y100 •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• ••Y100 •• •• •• bnf-kc.com bnf-kc.com bnf-kc.com bnf-kc.com bnf-kc.com .O. 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FeePB Br:: he888oooe111xxn:666•e822... :Fax 177619977.6311.. .22471166816.756.3659 6422592244.99│11288E222 m9||1.866.756.3313 77681 F 816.756.3313 T3a6oonll|lls Ta F orrsleel eeCF:: ir88te55y•e55,:Toll .8M 2545O99. 2..Free 7833766.|2||6KT 8F a x : 8 1 6 . 7 5 6 . 3 6 5 9 P hh oo nn ee :: 88 11 66 .. 77 77 77 .. 22 66 33 66 || T T oo ll ll F F rr ee ee :: 88 55 55 .. 22 44 99 .. 22 22 99 88 P BUG I understand that if I or my dependents provide false information to the Ironworkers Welfare Fund or conceal information, we could be subject to severe penalties under state and federal law and the Fund may seek to recover benefits wrongfully paid or pursue legal remedies against us. I declare under penalty of perjury that the foregoing is true and correct. AUTHORIZATION I agree, for myself and my dependents, that in the eventany health services provided are the primary responsibility of any other party by way of other of another person to fully inform Ironworkers Welfare Fund and that I will execute such assignments, group health coverage or by the actof omission liens or other documents which maybe necessary to enable Ironworkers Welfare Funds to recover the value of benefits provided. I further agree that in the event I or any of my dependents other party who has primary responsibility for services provided, I will collect benefits or damages from any immediately reimburse Ironworkers Welfare Funds to the extent of services provided and to the extent as specified by the plan. FRAUD WARNING files an application for benefits or statement of claim containing any Any person who, knowingly and with intent to defraud the Fund or other person: (1) materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits, a fraudulent act and may be subject legal action FOR INTERNAL USE ONLY MC _______ BCONLY REC: _______ DD REC: _______ REQ ON: _______ BY: _______ FORREC: INTERNAL USE MC REC: _______ BC REC: _______ DD REC: _______ REQ ON: _______ BY: _______ FOR INTERNAL USE ONLY MC REC: _______ BC REC: _______ DD REC: _______ REQ ON: _______ BY: _______ FOR INTERNAL USE ONLY MC REC: _______ BC REC: _______ DD REC: _______ REQ ON: _______ BY: _______ Y100 Y100 Y100
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