1199SEIU Enrollment Form

ENROLLMENT CHANGE FORM

Formulario de Cambio de Matricula

This form is not valid for your initial enrollment in the 1199SEIU Benefit Fund • Este formulario es valido para la primera matricula en el Programa de Beneficio de 1199SEIU

Member Eligibility Dept. • P.O. Box 838 • New York, NY 10108-0838
www.1199nbf.org

Member’s Present Name     SS#

Nombre del Miembro Presente

NAME OF YOUR EMPLOYER

CHECK OFF AND COMPLETE ONLY THE SECTION WHERE YOU WISH TO CHANGE YOUR INFORMATION AND SIGN BELOW.

IF YOU ARE CHANGING YOUR NAME, ADDRESS, TELEPHONE NUMBER, SOCIAL SECURITY NUMBER, OR DATE OF BIRTH COMPLETE SECTION 1

IF YOU ARE ADDING OR REMOVING A DEPENDENT COMPLETE SECTION 2

IF YOU ARE CHANGING YOUR BENEFICIARY COMPLETE SECTION 3 (on reverse side)

X
MEMBER’S SIGNATURE DATE

IF YOU DO NOT SIGN AND DATE THIS FORM AND SEND THE RELATED DOCUMENTS, THE FORM WILL BE RETURNED AND THE INFORMATION WILL NOT BE PROCESSED.

SECTION 1 – MEMBER’S INFORMATION

OLD LAST NAME OLD FIRST NAME Initial

INCORRECT SS# NEW SS#

NEW LAST NAME NEW FIRST NAME Initial

OLD ADDRESS APT# CITY STATE ZIP CODE

NEW ADDRESS APT# CITY STATE ZIP CODE

OLD TELEPHONE NUMBER NEW TELEPHONE NUMBER

INCORRECT DATE OF BIRTH NEW DATE OF BIRTH

email:

SECTION 2 – NEW DEPENDENT(S)

ADD SPOUSE Initial

SEX F M    DATE OF BIRTH    DATE OF MARRIAGE    SOCIAL SECURITY NUMBER

SPOUSE’S PLACE OF EMPLOYMENT ADDRESS OF SPOUSE’S EMPLOYER CITY STATE ZIP CODE

REMOVE SPOUSE Date of Divorce/Legal Separation OR Date of Death

ADD ELIGIBLE CHILD(REN)

1 LAST NAME FIRST NAME Initial SEX F M DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER

2 LAST NAME FIRST NAME Initial SEX F M DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER

3 LAST NAME FIRST NAME Initial SEX F M DATE OF BIRTH RELATIONSHIP SOCIAL SECURITY NUMBER

SECTION 3 – BENEFICIARY INFORMATION FOR LIFE INSURANCE

Check this box if you authorize the Fund to assign up to 1/3 of your insurance benefit directly to the Funeral Home or cemetery.

1 LAST NAME OF BENEFICIARY FIRST NAME OF BENEFICIARY Social Security Number Primary Secondary

STREET ADDRESS OF PRIMARY BENEFICIARY CITY STATE ZIP CODE

This person is is not my spouse. RELATIONSHIP This person is a minor.

DATE OF BIRTH SEX F M

Guardian’s Information

LAST NAME FIRST NAME RELATIONSHIP TO BENEFICIARY

GUARDIAN’S STREET ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER

X
MEMBER’S SIGNATURE DATE

IF YOU DO NOT SIGN AND DATE THIS FORM AND SEND THE RELATED DOCUMENTS, THE FORM WILL BE RETURNED AND THE INFORMATION WILL NOT BE PROCESSED.