1199 Form – Fill Out and Use This PDF

1199SEIU GREATER NEW YORK BENEfiT 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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