CARPENTERS HEALTH & WELFARE FUND OF PHILADELPHIA & VICINITY ANNUAL ACTIVE MEMBER COORDINATION OF BENEFITS (COB) & ENROLLMENT FORM TO BE COMPLETED & RETURNED IN THE ENCLOSED ENVELOPE NO LATER THAN APRIL 1 ST, 2015 *SAVE TIME & SUBMIT ONLINE!! SEE REVERSE SIDE FOR DETAILS*
You can now submit your COB Online It is as easy as 1, 2, 3 1 and log in under the Go to www.mrcfunds.org Member Login The Instructions for logging in, user name and password can be found on the Fund s Website. If you have any issues logging in call (215) 568-0430. 2 Scroll down to the red I-Site banner, and click on the American Flag/ Union Banner 3 Agree to the Terms of Use then select 2015 COB Form You will then be taken to the COB Form. Simply follow the onscreen directions. You will receive a confirmation number when complete.
CARPENTERS HEALTH & WELFARE FUND 2015 COORDINATION OF BENEFITS & ANNUAL ENROLLMENT FORM Please complete ALL sections and return prior to the April 1 st, 2015 deadline Incomplete or unsigned forms will be returned Failure to return this form with all necessary information by April 1 st, 2015 will result in withheld future Cafeteria Benefit Payments Failure to re-enroll Eligible Children (age 19-26) will result in termination of their Health Coverage Member Information Please Print Clearly First Name Middle Initial Last Name SSN or UBC # Street Address City State Zip Code Home Phone Number Cell Phone Number Email Address Family Status Single - No Children Married - No Children Divorced/Widowed Single - With Children Married - With Children Do you, the member, have any other insurance besides the insurance which is provided by the Fund? Yes No Coverage Through Spouse Medicare : : : Medical Dental Vision Please Sign the Member Statement Form without a signature will be returned I would like to receive future correspondence from the Fund via E-mail and Text Member Statement: It is my responsibility, to ensure that all accurate information is maintained and kept updated regarding any Health Insurance. If other coverage is added or terminated for any individuals covered under my Group Insurance Program, I will notify the Fund immediately. I have read this Enrollment/COB Form (pages numbered 1 through 6) and I understand that the Carpenters Health and Welfare Fund ( Fund ) is an Employee Welfare Benefit Plan as defined under Employee Retirement Income Security Act of 1974 ( ERISA). I understand that any misrepresentation in the information I have provided above will permit the Fund to terminate the coverage of my Spouse, Minor Children, and/or Adult Children and seek any other legal remedies available including possible prosecution for fraud. I authorize the Fund to request and receive any Explanation of Benefits information from Independence Blue Cross. I am aware, and fully understand that if my Spouse has the capability to participate in, or purchase Health Coverage through their Employer; my Spouse is considered ineligible to receive Primary Health Care Coverage from the Carpenters Plan. I agree to immediately notify the Fund if my Spouse becomes eligible for Employer Sponsored Health Insurance. I authorize the Carpenters Health & Welfare Fund to exchange contact information only (Change of Address, Telephone Numbers, E-mail Addresses, etc.) with the Metropolitan Regional Council of Carpenters. X Signature of Member Date Page 1 of 6
Spouse Information: Spouse is Employed Spouse is Not Employed Spouse is Retired Along with the information on this page, effective February 2015, every spouse must complete the top portion of the Spouse Employment Verification Form located on page 3, whether you are employed or not employed. If employed, the bottom section of page 3 must be completed by the Employer. If employer sponsored insurance has been elected and copies of the card are included, your employer does not need to sign Page 3. The Spouse Employment Verification Form must be returned along with the 2015 Coordination of Benefits form. If not included, the entire Coordination of Benefits Form will be returned. To enroll your Spouse for the first time, please include a copy of their Birth Certificate, Social Security Card and Marriage Certificate. Failure to elect employer offered coverage will result in loss of Primary Coverage through the Fund and no payment for claims. Failure to select Enroll and return this form by April 1st, 2015 could result in termination of Health Insurance Coverage. Enroll First Name Middle Initial Last Name Sex Social Security Number Date of Birth Marriage Date Insured By Medicare Single Coverage Family Coverage Covered Benefits Medical Dental Vision X Signature of Spouse Date Copy of any OTHER Health Insurance Card Please DO NOT include Carpenters Health Insurance Card Copy of any OTHER Health Insurance Card Please DO NOT include Carpenters Health Insurance Card Copy of any OTHER Health Insurance Card Please DO NOT include Carpenters Health Insurance Card Copy of any OTHER Health Insurance Card Please DO NOT include Carpenters Health Insurance Card Page 2 of 6
SPOUSE EMPLOYMENT VERIFICATION FORM Effective February 2015, if employer provided coverage is newly elected or is continued from the previous year for Health Insurance, this Verification Form must be completed. This form must be completed and returned to the Fund Office along with the 2015 Coordination of Benefits form. Member Name: Spouse s Name: UBC # or Last Four of SSN: Spouse s Date of Birth: Please check ONE of the following below I am not currently employed/have not been employed in the last year I am currently employed My Company does offer Health Insurance My Company does not offer Health Insurance I am no longer employed; Last day of employment: My Health Coverage was terminated on: (copy of Termination Letter MUST be attached) I am self-employed. (Please complete and sign the bottom portion of this form) Section below must be completed and signed by Employer if copies of Employer sponsored insurance cards are not provided Employee Name: Is Health Care Coverage available to the Employee named above? YES NO Is the Employee named above currently enrolled in Health Care Coverage? YES NO If yes, please indicate which benefits the Employee has elected. : : Type: PPO HMO P.O.S HSA High Deductible Health Plan Other: Covered Benefits: Medical Dental Vision If no, why is the Employee named above not enrolled in Health Coverage? Waiting Period; When will they be eligible for benefits? Eligible, but is waiting for Open Enrollment. When will Open Enrollment take place? Health Coverage is not offered. Reason: Employee did not elect to enroll in Health Coverage Other: Please Explain Employer Name: I hereby certify the person stated on this form is an Employee and the information above is accurate and complete to the best of my knowledge Employer Representative Signature and Name Printed : E-Mail: Phone Number MEMBER/SPOUSE AUTHORIZATION AND SIGNATURES (IN ORDER FOR THIS FORM TO BE COMPLETE BOTH MUST SIGN) We hereby declare under penalty of perjury that we are legally married and the information on this form is correct and complete to the best of our knowledge. We authorize the Carpenters Health & Welfare Fund to verify the spouse s employment status as needed. If requested by the Fund, we agree to obtain and furnish a copy of any marriage certificate, divorce decree, or other relevant document. We understand that if any incorrect or misleading information results in a loss to the Fund, the Fund is entitled to recover the amount of such loss from us or by withholding from our future benefits. Employed Spouses Only: I hereby authorize my employer or other entities to release information regarding my employer s health insurance plan and my eligibility status for coverage under that plan to the Fund. Member Signature Date Spouse Signature Date Page 3 of 6
Dependent Information: Children (Age 0-26) Please list all Children age 0-26 below, and indicate in the Enroll column anyone you wish to have covered by the Health Insurance provided by the Fund. Any Child listed below must meet the definition of an Eligible Family Member listed in the Summary Plan Description page HW3. In order to enroll Children for the first time, please submit a copy of the Child s Birth Certificate and Social Security Card to the Fund Office. To enroll step-children for the first time, please include a copy of their Birth Certificate, Social Security Card and a notarized Letter of Sole Support. Failure to select Enroll for any Child (Age 19-26) and return this form by April 1st, 2015 will result in termination of Health Insurance Coverage and loss of eligibility to enroll until the following plan year. Please note, employment/school status is not a requirement to enroll. Children (Age 19-26 ) are not required to elect Employer Sponsored Coverage. If coverage is elected, the Fund will coordinate as Secondary. In order to qualify for coverage through the Fund, the following information is required on an annual basis to re-enroll Children over the age of 19. Enroll Eligible Children (Age 0-26) (First Name, Middle Initial, Last Name) Relationship Birth Date Social Security Number If Any Child listed above has Health Insurance Coverage other than the Benefits provided by the Carpenters Health & Welfare Fund, please complete the corresponding boxes below. Must provide copy of Insurance Cards. If any Child (Age 0-26) is on State Sponsored coverage, on their own plan, please indicate Self as If any Child (Age 19-26) is employed and has coverage through their employer please indicate Self as If additional boxes are needed for Eligible Children please see reverse side Page 4 of 6
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2015 COORDINATION OF BENEFITS DOCUMENT CHECKLIST Are all pages requiring signatures signed and dated? If you or your Spouse are currently enrolled in Medicare, please include a copy of your and/or your Spouse s Medicare Card if you have not previously provided the Fund with a copy of your card. If enrolling a Spouse for the first time, please include a copy of the Marriage Certificate, Birth Certificate and the Spouse s Social Security Card. Include the Spouse Employer Verification Form (whether spouse is employed or not). The COB will be returned if the verification form is not included or signed by employer, member and spouse. If enrolling new eligible children, please include a copy of the Birth Certificate and Social Security Card. If enrolling a Step-Child for the first time, please include a copy of the Birth Certificate, Social Security Card and a notarized Letter of Sole Support. Are all 19-26 year old children listed on this form that you wish to have re-enrolled for the 2015 benefit period? Did you check off the applicable ENROLL boxes for all eligible family members (spouse, children 0-26) that you wish to have covered by the Fund for this plan year? Please include copy of Insurance Cards for any Eligible Family Member(s) other than the Insurance provided by the Fund. Page 6 of 6