Pipe Fitters Local No. 533 Health and Welfare Plan
8600 Hillcrest Road, Suite A  | Kansas City, Missouri 64138 | (p) 816.361.0206 |  (f)  816.444.4275

ENROLLMENT FORM

Directions: Complete this Enrollment Form and return it to the Fund Office. You must submit the following items to the  Fund Office with this Enrollment Form, if you have not previously provided them to the Fund Office (as applicable):
•	If you or your Dependent(s) have other group medical coverage, you must include a photocopy of the front and back of the I.D. card for the other coverage. If your other coverage is Medicare, please complete the backside of this form
•	If you are married, you must include a copy of your Marriage Certificate.
•	If you are enrolling a Dependent child(s), you must include a copy of the child’s birth certificate, adoption papers, or court order for custody and support or maintenance (as applicable).

Pipe Fitter Information:

Name:	Social Security Number:	
Date of Birth:	Phone Number:	
Address:	Marital Status: q Single  q Married  q Divorced  q Widowed

Do you have other insurance?  Yes q	No q	(If Yes, please attach copy of other insurance ID card or if your other coverage is Medicare, please complete the backside of this form.)	

   SPOUSE INFORMATION:
   Make sure you fill out all the information for your spouse.

Spouse’s Name	
Date of Birth	
Social Security Number
	
 Sex	
Do you currently have    other insurance?	
Coverage Type	
				    Yes  No 	
	       Medical/Rx                            
       Vision  
       Dental
		
 DEPENDENT CHILD INFORMATION:
Make sure you fill out all of the information for each Dependent child that is eligible for coverage from the Plan. It is extremely important that you list each of your Dependent children that is under the age of 26. If you have more than six eligible    Dependents, attach a separate sheet of paper to this Enrollment Form that includes information regarding those additional   Dependents.

Dependent's Name	Relationship	Date of Birth	Social Security Number	Sex	Do they have other insurance?	Coverage Type	
					       Yes  No 	    Medical/Rx
    Vision
    Dental 	
					       Yes  No 	    Medical/Rx
    Vision
    Dental	
					       Yes  No 	       Medical/Rx
       Vision
       Dental	
					       Yes  No 	       Medical/Rx
       Vision
       Dental

The following is extremely important information. Please read this language carefully and then sign and date this Enrollment Form and return it to the Fund Office. If you are married, both you and your spouse must sign and date this Enrollment Form.

I hereby certify that all information on provided on this Enrollment Form is correct to the best of my knowledge. I understand that if this information changes, it is my responsibility to notify the Fund Office immediately.  I also understand that I will be required  to reimburse the Plan for any payments made as a result of my failure to notify the Fund Office of a change in the information provided on this Enrollment Form.

Participant’s Signature	Date of Signature

Spouse’s Signature	Date of Signature

Medicare Information Including Medicare Part D – Prescription Drug Program (If applicable)

Your Name: 	Date of Birth 	/ 	/ 	

Effective Date: Part A: 	/ 	/ 	Part B: 	/ 	/ 	Part D: 	/ 	/ 	

Do you have Medicare due to End-stage renal disease? Yes q	No q	If Yes, Effective Date: 	/ 	/ 	

Spouse’s Name: 	Date of Birth 	/ 	/ 	

Effective Date: Part A: 	/ 	/ 	Part B: 	/ 	/ 	Part D: 	/ 	/ 	

Do you have Medicare due to End-stage renal disease? Yes q	No q	If Yes, Effective Date: 	/ 	/ 	

Other’s Name: 	Date of Birth 	/ 	/ 	

Effective Date: Part A: 	/ 	/ 	Part B: 	/ 	/ 	Part D: 	/ 	/ 	

Do you have Medicare due to End-stage renal disease? Yes q	No q	If Yes, Effective Date: 	/ 	/ 	

Life-Changing Events

When you get married, provide the Fund Office with:
•	A copy of your marriage certificate
•	Your spouse's date of birth
•	A copy of your spouse's medical insurance information, if he or she is covered under another plan

If you add a child, provide the Fund Office with:
•	A copy of the child’s birth certificate, adoption papers, or court order for custody and support or maintenance (as applicable)
•	A copy of your child's other medical insurance information, if he or she is covered under another plan

If you get legally separated or divorced, provide the Fund Office with:
•	A copy of your separation or divorce decree
•	A copy of any QDRO
•	If you have children for whom you do not have custody, a copy of any QMCSO

Life changing events are all subject to the terms of the Pipe Fitters Local No. 533 Health and Welfare Plan Document. If you have any questions regarding enrollment, please see your Summary Plan Description or contact the Fund Office.