Enrollment Information - Mo-Kan Iron Workers Trust Funds

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Middle Initial
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Social Security Number
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Birth Date (MM/DD/YYYY)
Area Code Phone Number
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Home Address
Apartment Number
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State
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
 
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 
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City
County






Check One:  Single
 Married
 Widowed  Separated
 Divorced:

of Divorce (MM/DD/YYYY)


Date

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
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 



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 hasnot 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.
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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
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




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

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





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




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 eventany 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 actof 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
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FOR INTERNAL USE ONLY
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