Continued Eligibility Form | Plumbers & Steamfitters Local Union 33

Please choose your status:*
- Single, Separated, Divorced or Widowed
- Married and your spouse does not work outside of the home
- Married and your spouse does work outside the home
- I am a dependent age 19 and over and am already enrolled in the Plan
First Name*
Last Name*
Participant Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Secondary Phone
Email
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Relationship
Emergency Contact Phone
Have you served in the military?*
- Yes
- No
When did you serve?*
Do you have any medical conditions which occurred during your service?*
- Yes
- No

Military Medical Conditions

If yes, please detail all illness and injuries below and if you have VA benefits for them.

Date of injury or illness	Type of inury/illness	Do you qualify for VA Health Care Benefits for this condition?	Actions

There are no Medical Conditions.

Date of Marriage*
Spouse's First Name*
Spouse's Last Name*
Spouse's Address*
Spouse's Phone*
My spouse is*
- self-employed
- not employed outside the home
My spouse is*
- employed part-time
- employed full-time
- self-employed
If part-time, how many hours regularly scheduled each week?*
Spouse Employer Name*
Spouse Employer Address*
Street Address Address Line 2 City State ZIP Code
Spouse Employer HR Contact Person*
Spouse Employer HR Contact Phone*
Information about my Spouse's Insurance Options through his/her Employer*
- My spouse is eligible for group health coverage through his/her employer, but has declined coverage
- My spouse is currently covered by his/her employer's health insurance
Spouse's Health Insurance Options file upload*
Max. file size: 50 MB.
If "declined", please explain why*
Name of health plan or insurance company*
Indentification/Policy Number*
Coverage Includes (check all that apply)*
- Medical
- Dental
- Rx Drugs
- Vision
Coverage is for*
- Employee only
- Employee and Spouse
- Family
Effective Date of Coverage*
MM slash DD slash YYYY
Use this area to provide additional information and/or explanations
Are you offered any type of FSA (Flexible Spending Account), HRA (Health Reimbursement Account) or HSA (Health Savings Account) by your employer?*
- Yes
- No
If YES, did you elect that coverage?*
If YES, what type of coverage did you elect?
Does your spouse have Medicare benefits due to disability?*

List Dependents

Name	Relationship	Does This Child Have Coverage?	Actions

There are no Dependents.

Effective Date of Medicare Disability Coverage*
MM slash DD slash YYYY
Member First Name*
Member Last Name*
Dependent First Name*
Dependent Last Name*
Dependent Address*
Street Address Address Line 2 City State ZIP Code
Dependent Phone*
I am a dependent, age 19 and older and am*
- not employed and/or a college student
- employed full-time
- employed part-time
Dependent Email
Has the dependent served in the military?*
- Yes
- No
When did the dependent serve?*
Does the dependent have any medical conditions which occurred during service?*
- Yes
- No

Military Medical Conditions

If yes, please detail all illness and injuries below and if you have VA benefits for them.

Date of injury or illness	Type of inury/illness	Do you qualify for VA Health Care Benefits for this condition?	Actions

There are no Medical Conditions.

Marital Status*
Marital Status (19)*
Date of Marriage*
Date Separated*
Date of Divorce*
Does the dependent have other insurance?*
- Yes
- No
Policy Holder Name*
Relationship to Policy Holder*
Policy Holder's Date of Birth*
MM slash DD slash YYYY
Name of Insurance Company*
Policy Number*
Effective Date*
Coverage Includes (check all that apply)*
- Medical
- Dental
- Rx Drugs
- Vision
Are you offered any type of FSA (Flexible Spending Account), HRA (Health Reimbursement account) or HSA (Health Savings Account) by your employer?*
- Yes
- No
Did you elect the FSA, HRA or HSA?*
- FSA
- HRA
- HSA
Dependent Signature*
I declare that the information is true and correct to the best of my knowledge, information and belief. I understand that the Fund reserves the right to suspend or terminate my health coverage if it concludes that I have provided false or misleading information in this Declaration. I understand that I am eligible for coverage until age 26. I also understand that if I have other health coverage through employment or my spouse, that coverage will be the primary insurance plan. The Fund will only consider claims for payment that have first been submitted to my primary health insurance carrier. Finally, I understand if I should change employment, get married or have any other event that may cause my eligibility for health coverage to change, I am required to notify the Fund Office and complete an updated Declaration of Dependent Health Coverage.
Participant Signature*
Under penalties of perjury, I/We jointly declare that the information contained in this document is true and correct to the best of my/our knowledge, information and belief. I/We understand that the Fund reserves the right to suspend or terminate my/our health coverage if it concludes that I/We have provided false or misleading information on this form. I/We hereby authorize all doctors, pharmacists, hospitals, or other institutions rendering care and treatment to furnish the Plumbers and Steamfitters Health & Welfare Fund with information regarding benefits to which I/We may be entitled. A copy of the authorization shall be considered as effective and valid as the original.
Participant Signature*
Under penalties of perjury, I/We jointly declare that the information contained in this document is true and correct to the best of my/our knowledge, information and belief. I/We understand that the Fund reserves the right to suspend or terminate my/our health coverage if it concludes that I/We have provided false or misleading information on this form. I/We hereby authorize all doctors, pharmacists, hospitals, or other institutions rendering care and treatment to furnish the Plumbers and Steamfitters Health & Welfare Fund with information regarding benefits to which I/We may be entitled. A copy of the authorization shall be considered as effective and valid as the original. I/We understand that if my spouse’s employer offers group health insurance, my spouse must enroll in his/her employer’s plan unless it meets criteria stated on reverse side. I/We also understand that we are required to submit documentation from his/her employer showing that the criteria is met. I/We understand that if my spouse does not enroll, he/she is ineligible to be covered as a dependent on Plumbers and Steamfitters Local 33 Health Plan. Finally, I/We understand that my spouse’s group health plan from his/her employer is his/her primary insurance plan. The Fund will only consider claims for payment that have first been submitted to my spouse’s employer plan. If my spouse should change employment, or his/her eligibility for health coverage should change, I am required to notify the Fund Office and complete an updated Declaration of Spouse Health Coverage. I/We jointly certify that the above information is true and correct. I/We hereby authorize all doctors, pharmacists, hospitals, or other institutions rendering care and treatment to furnish the Plumbers and Steamfitters Health & Welfare Fund with information regarding benefits to which I/We may be entitled. A copy of the authorization shall be considered as effective and valid as the original.
Spouse Signature*

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