Retirement Health Benefit Group Insurance Inquiry Form
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1Teamsters Joint Council No. 83 of Virginia
Health & Welfare and Pension Funds
8814 Fargo Road ∙ Suite 200 ∙ Richmond, VA 23229
Phone (804) 282-3131 ∙ 800-852-0806 ∙ Fax (804) 288-3530
Retirement Health Benefit Group Insurance Inquiry
1.
Are you employed?
Yes
No
Employer’s name and full address:
__________________________________________________________________________________________
__________________________________________________________________________________________
2.
Are you covered by other group health coverage?
Yes
No
Carrier’s Name, full address and contract/policy number: _____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3.
Are you married?
Yes
No
Spouse’s name ____________________________________________
Spouse’s SSN _____________________________
Spouse’s date of birth ________________________
4.
Is your spouse employed?
Yes
No
Employer’s name and full address:_____________________
__________________________________________________________________________________________
__________________________________________________________________________________________
5.
Is your spouse covered by other group health insurance?
Yes
No
Carrier’s Name, full address and contract/policy number: ____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
6.
Do you have dependent children who had health coverage under this plan when you retired?
Yes
No
Complete the following for each dependent (use back of form if needed)
Dependent child’s name
SSN
Date of Birth
__________________________________________________________________________________________
__________________________________________________________________________________________
7.
Are any of the listed dependent children employed?
Yes
No
If yes, list the dependent’s name
and the dependent’s employer’s name and address:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
8.
Are any of the listed dependent children covered by other group health coverage?
Yes
No
Carrier name, full address and contract/policy number for each dependent:
__________________________________________________________________________________________
__________________________________________________________________________________________
9.
Are you covered by Medicare?
Yes
No
If yes, submit a copy of the Medicare card unless previously
submitted.
10.
Does Medicare cover your spouse or any of your dependent children?
Yes
No
N/A
If yes, submit a copy of the Medicare card unless previously submitted.
11.
Are you, your spouse or dependent children receiving Social Security Disability Benefits?
Yes
No
If yes, submit a copy of the Disability Award letter.
I hereby verify that all of the above information is accurate and true.
Participant’s Signature ___________________________________________________ Date _______________________
Participant’s Printed Name ___________________________________ UID________________ Birth Date ____________
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