Transcription of HEALTH 37SECURITY AND (PLEASE READ ATTACHED …
1 SECURITYGENDERHome E-Mail Address (Optional) Phone # of Insurer( ) -WORK PHONE( ) -( ) -ZIP CODEDATE OF HIRE MONTH DAY YEARCHANGE OF status FORMMIIf you enroll any dependents, spouse or domestic partner, it is mandatory that you attach all required documents ( BIRTH CERTIFICATE, MARRIAGE CERTIFICATE, ADOPTION DOCUMENTS, REGISTRATION OF DOMESTIC PARTNERS or DIVORCE PAPERS) beforeany benefits will be provided to dependents, spouse or domestic B: CHANGE OF MEMBER S INFORMATIONZIP CODEPHONE No. of SPOUSE/DOMESTIC PARTNER S UNION/LOCAL ( ) -( ) -CITYSTATED entalDrugHealth InsuranceBenefitName of InsurerAddress/Zip Code of InsurerPolicy #Coverage Individual or FamilyNAME OF SPOUSE/DOMESTIC PARTNER S UNION/LOCAL # IF APPLICABLEADDRESS/ZIP CODE OF SPOUSE/DOMESTIC PARTNER S UNION/LOCAL # IF APPLICABLEWORK PHONEWORK ADDRESSNAME OF EMPLOYER DATE OF BIRTH MONTH DAY YEARGENDER SS# OF SPOUSE/DOMESTIC PARTNERLAST NAME (If Different)FIRST NAMEMIHOME STREET ADDRESSCHANGE OF FIRST NAMECHANGE OF LAST NAMEAND55 Water Street, New York, NY 10041 Telephone: (212) 815 - 1234 Fax: (212) 298-9880 or Email: /.
2 MONTH DAY YEAR MONTH DAY YEAR / / . MONTH DAY YEAR/ / .WIDOWED (W) MONTH DAY YEAR/ / .DOMESTIC PARTNER (PS) MONTH DAY YEAR/ / .NOTE: A date is required if an option other than single is selectedMALEFEMALEDATE OF BIRTH MONTH DAY YEARCOMPLETE OTHER SIDE :FEMALE(PRINT OR TYPE IN BLACK INK AND IN CAPITAL LETTERS)(PLEASE READ ATTACHED INSTRUCTIONS BEFORE COMPLETING THIS FORM)MALEMARRIED (M)SEPARATED (S)SINGLE (S)DIVORCED (D)SECTION C: SPOUSE OR DOMESTIC PARTNER INFORMATION (If not applicable, please indicate none)(PLEASE FILL IN CHANGES ONLY BELOW THIS LINE)SOC. SEC. NAME AS CURRENTLY ENROLLEDFIRST NAMEMID. status :Please check one PHONECELL PHONESECTION A: FIRST NAMEFIRST NAMEFIRST NAMEFIRST NAMEDEPENDENT SS#GENDERDATE OF BIRTHLAST NAME (IF DIFFERENT)DEPENDENT SS#GENDERDATE OF BIRTHLAST NAME (IF DIFFERENT) MONTH DAY YEAR/ /.
3 LAST NAME (IF DIFFERENT)GENDERDATE OF BIRTH MONTH DAY YEAR/ / .DEPENDENT SS#OTHER: RELATIONSHIPSECTION D: DEPENDENT INFORMATION (NOTE - If there are additional dependents, please list on a separate page.)DEPENDENT SS#ATTENTION : I attest that the information entered on this form is true and accurate and I understand that I and my family may lose benefit coverage if any of the information given on this form is OF BIRTHLAST NAME (IF DIFFERENT) MONTH DAY YEAR/ / .OTHER: RELATIONSHIPOTHER: RELATIONSHIPOTHER: RELATIONSHIP MONTH DAY YEAR/ / .SONDAUGHTERSTEP-SONSTEP-DAUGHTERSONDAUG HTERSTEP-SONSTEP-DAUGHTERSONDAUGHTERSTEP -DAUGHTERSTEP-SONDAUGHTERSONSTEP-DAUGHTE RSTEP-SONMALEFEMALEFEMALEMALEFEMALEMALEF EMALEMALEDear Member:The function of this form is to provide you with an opportunity to update your DC 37 HEALTH & Security Plan records.
4 Updating your records will ensure that you and your dependents will receive your benefits more NOTE THE "A" must be must fill in your Social Security Number or PID only the parts of this form for which the status of you or your dependents has the necessary documentation to your Change of status Form. (Birth Certificate foradditional children, Marriage Certificate for change of name or marital status and RegistrationCertificate for addition of domestic you are adding a Spouse/Domestic Partner to your enrollment records, you must alsocomplete the section entitled "Spouse's/Domestic Partner's Employment information." you wish to change and/or add a beneficiary, request a Change of Beneficiary form from the , this form is not valid unless you, the Member, sign and date fax the form to us at (212) 298- 9880 or email at for faster more information about your Plan and your benefits call the Inquiry Unit at (212)815-1234 XMEMBER/EMPLOYEE SIGNATUREDATERev.)
5 6/15
