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Participant Information
Gender: 
Last Name:  First Name:  Middle Initial: 
SSN:  Birth Date:  Phone: 
Address:  Apartment #:  E-mail: 
City:  County:

State:
Zip: 
Check One:  Divorce Date: 
Check the following languages in whcih you are literate:  Other: 
Are you a policyholder of any other group medical, vision, or dental plan other than Medicare? 
Are you entitled to Medicare Part A or B?  If yes, submit a copy of your Medicare card if it has not been previously submitted.
Is your spouse offered group health coverage through his/her employer (whether they have accepted the other coverage or not)? 
Dependent Information
List all eligible dependents to be covered. If you are adding a spouse, please include a copy of your marriage certificate. County filed copies only. Souvenir copies are not accepted. If you are adding a child, please include a copy of their birth certificate. State issued copy only. Souvenir copies are not accepted.


If either you or your spouse are divorced and you are adding a child or stepchild, submit a copy of the divorce decree and any settlement agreement made part of the decree stating custody and medical responsibility for the children. The decree must be signed and dated by the judge.


Declaration Of Other Coverage
Please complete for the Participant and each dependent that has any other group medical, vision, prescription, or dental coverage (including Medicare). Attach a seperate sheet if necessary. Submit a copy of card(s) for each carrier.
Other Coverage #1
Policy Holder: Policy Number:
Policy Holder's SSN: Dependents Covered?
Plan Name: Employer's Name:
Plan Address: Plan Phone:
Plan City, State, Zip:    
Status Of Coverage: Follows Birthday Rule?
Effective Date Of Coverage: Termination Date:
Benefits Provided:
Medical: Dental:    Vision:
Mental Health/Substance Abuse: Prescription:
Other Coverage #2
Policy Holder: Policy Number:
Policy Holder's SSN: Dependents Covered?
Plan Name: Employer's Name:
Plan Address: Plan Phone:
Plan City, State, Zip:    
Status Of Coverage: Follows Birthday Rule?
Effective Date Of Coverage: Termination Date:
Benefits Provided:
Medical: Dental:    Vision:
Mental Health/Substance Abuse: Prescription:

I understand that if I or my dependents provide false information to the Boilermakers National Health & Welfare Fund or conceal information, we could be subject to severe penalties under state and federal law and the Fund may seek to recover benefits wrongfully paid or pursue legal remedies against us. I declare under penalty of perjury that the foregoing is true and correct. I agree, for myself and my dependents, that in the event any health care services are the primary responsibility of any other party by way of other group health coverage or by the act of omission of another person to fully inform Boilermakers National Health & Welfare Fund and that I will execute such assignments, liens or other documents which may be necessary to enable Boilermakers National Health & Welfare Fund to recover the value of benefits provided. I further agree that in the event I or any of my dependentscollect benefits or damages from any other party who has primary responsibility for services provided, I will immediately reimburse Boilermakers National Health & Welfare Funds to the extent of services provided and to the extent specified by the plan. FRAUD WARNING Any person who, knowingly and with intent to defraud the Fund or other person: (1) files an application for benefits or statement of claim containing any materially false information; or (2) conseals for the purpose of misleading, information concerning any material fact hearto, commits, a fraudulent act and may be subject to legal action.

Checking the box and submitting this form serves as the participant’s electronic signature.

   

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