Enrollment Form - Your fringe benefit package includes a health and security plan, life insurance benefits, two pension plans, and a vacation plan. Before you and your eligible dependents can participate in these plans,
you must complete this form in its entirety and return it to the Trust Office.
If you are adding a Domestic Partner, please write or type "Domestic Partner" under the Relationship heading. If you are enrolling a dependent child of your Domestic Partner, please write or type "Partner, Dependent" under the Relationship heading.
Enrollment Form - Surviving Spouse - If you are the surviving spouse of a deceased participant, use this form to enroll for continuing health coverage under the Plan.
Change of Address - This the the Change of Address notice. Please fill out this form and submit it to the Trust Office if your address has changed.
Authorization To Transfer Fringe Benefit Contributions - Participants in the Trust may use this form to authorize the transfer of fringe benefit contributions.
Child Enrollee Questionnaire - This Child Enrollee Questionnaire is used to establish basic facts about the child being enrolled in the plan.
Stepchild Update - To help us keep our eligibility files current, please use this form to provide us with information concerning your stepchild.
National Student Clearinghouse - Student Authorization - If you have a dependent child who is or will be attending an accredited college, university, technical trade, or mechanical school on a full-time basis, please have the student complete the questions below, sign and date it, and then return this form to the Trust Office. Receipt of this signed form is this plan's permission to access enrollment status on this student for a period of three years.
Student Questionnaire - Please answer the questions on this form and provide proof of full-time student status for applicable quarters. This will be used to determine the student's eligibility under the plan.
Summer Student Questionnaire - Please answer the questions on this form and provide proof of full-time student status for applicable quarters.
Affidavit of Domestic Partnership - Complete this form and have it notarized. Be sure to send the documentation of joint financial responsibility requested on the Affidavit.
Domestic Partner Coverage - Affidavit of Dependent Status - Read the Explanation of Tax Issues Associated with Coverage for Domestic Partner. If you are seeking to establish that your
Domestic Partner is a dependent for federal tax purposes, then complete the Affidavit of Dependent Status and have it notarized.
If you are not seeking to establish dependency for tax purposes, you do not need to complete the form. The Trust will automatically assume that the value of health insurance for your Domestic Partner is taxable income, in accordance with IRS regulations. The Trust Office will send you an invoice for your first withholding payment and monthly remittance notices thereafter.
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Self Contribution
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