The 1199SEIU Greater New York Benefit Fund offers Young Adult Coverage for dependent children of members from age 19 up to age 26. This enrollment form lets you continue or initiate benefit fund coverage for a child who has aged out of automatic coverage.
To complete the form, you will need to provide your full member name, member ID, address, and contact details. You also need to supply your dependent's full name, date of birth, and Social Security number. Coverage options include medical, dental, and vision plans. The form also asks whether the other parent has access to employer-sponsored health insurance, which may affect the coverage plan selected.
Required supporting documents include a copy of the dependent's birth certificate and Social Security card. These verify the relationship between the member and the young adult. By signing the form, both the member and dependent authorize the release of health-related information for benefits administration. Learn more about related coverage options through our 1199SEIU form and health insurance application pages.
| Question | Answer |
|---|---|
| Form Name | 1199 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | 1199 forms, 1199seiu application form, 1199 seiu benefits forms, 1199 union application |