1199 Form PDF Details

Securing health insurance coverage for young adults has become a crucial step in ensuring their well-being and financial stability. The 1199SEIU Greater New York Benefit Fund has recognized this need and offers a straightforward solution through its Enrollment Form for Young Adult Coverage. Targeted at children of members from age 19 up to age 26, this specific form facilitates the continuation or initiation of benefit fund coverage, addressing an essential coverage gap that many young adults face. Required documentation includes a copy of the child's birth certificate and social security card, ensuring both the member and dependent's identities are verified. This meticulous process underlines the importance of accurate member information, including full name, ID, and contact details, alongside the young adult’s details and insurance coverage preferences ranging from medical to vision. Additionally, the form queries about the other parent's access to health insurance, which could impact the dependent's coverage plan. By signing the form, members and their dependents authorize the release of health-related information necessary for benefits administration and acknowledge the fund's right to reimbursement for expenses paid due to third-party actions. This process is not just about enrolling in a plan; it's a commitment to transparency, accountability, and the health security of the next generation. Compliance with these procedures ensures the seamless extension of benefits, safeguarding young adults during a pivotal time in their lives.

QuestionAnswer
Form Name1199 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names1199 forms, 1199seiu application form, 1199 seiu benefits forms, 1199 union application

Form Preview Example

1199SEIU GREATER NEW YORK BENET FUND

330฀West฀42nd฀Street,฀New฀York,฀NY฀10036-6977฀•฀www.1199SEIUBeneits.org Tel฀(646)฀473-9200฀•฀Outside฀NYC฀Area฀Codes:฀(800)฀575-7771

Enrollment Form for Young Adult Coverage

Instructions

1.Complete a separate application for Young Adult coverage for each dependent child from age 19 up to age 26 for whom you are requesting Benefit Fund coverage.

2.Send a copy of your child’s Birth Certificate and Social Security Card along with this completed form, signed by the member and the dependent, to:

1199SEIU Benefit and Pension Funds · Member Eligibility Department

PO Box 1035 · New York, NY 10108-1035

Member’s Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member’s Full Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member ID:

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

/

 

 

/

 

 

 

 

 

 

Sex:

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip Code:

 

 

 

Home Telephone: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell #: (

 

 

 

)

 

 

 

 

 

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Young Adult’s Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent’s Full Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security #:

-

 

 

-

 

 

 

 

 

 

 

Date of Birth:

 

 

/

 

 

/

 

 

 

 

 

 

Sex:

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

 

 

Year

 

 

 

 

 

 

Address (if different from member):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip Code:

 

 

 

Home Telephone: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cell #: (

 

 

 

)

 

 

 

 

 

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does Your Dependent’s Other Parent Have Access to Other Health Insurance?

Yes

 

 

No

 

 

 

 

 

 

If Yes, Please Provide Other Parent’s Full Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Parent’s Date of Birth:

 

 

/

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes to the above, please provide Other Parent’s Employer Information:

Employer’s Full Name:

Employer’s Address:

 

 

 

 

 

 

 

 

City:

 

State:

 

Zip Code:

Employer’s Telephone: (

 

)

 

 

 

 

 

 

 

 

 

 

 

 

Please Indicate the Type of Coverage (Check all that apply):

 

 

 

 

 

 

Medical

Hospital

Prescription

 

Dental

Vision

 

 

 

Effective Date of Coverage:

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month Day Year

Name of Insurance Plan:

Policy/Group Number:

 

Insurance Plan Telephone: (

)

 

 

 

 

 

This enrollment form is for Fund use only, and it will not be released to any third party except where necessary for the administration and operation of the Fund, or where otherwise required by law. The foregoing statements are to the best of my knowledge true and complete. I authorize any hospital, physician or other healthcare provider to release to the Fund and its agents any records of information, without restric- tion, concerning me or any member of my family receiving benefits from the Fund. Unless I revoke it in writing, this authorization will be effective as long as I am a participant in the Fund. A photocopy of this authorization shall be as valid as the original. I understand that under the terms of the plan (SPD), the Fund has a right to be reimbursed for any money it pays on my behalf for expenses caused by a third party. If the Fund pays any such claims, it will have a lien on payments I receive from, or on behalf of, the third party, and I agree to pay back the Fund for any payments it has made. This agreement will be effective for all benefits incurred while I am a participant in the Fund, even if I receive payments from, or on behalf of, a third party when I am no longer a participant.

 

 

I certify that the foregoing is true and correct.

Member’s Signature X

 

 

Date:

Dependent’s Signature X

 

Date:

You and your dependent must sign the form or it will be returned and your dependent will not be enrolled.

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