Spouse/dependent Questionnaire - Hawaii Electricians Health & Welfare Fund
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2HAWAII ELECTRICIANS HEALTH & WELFARE FUND
1935 Hau Street, Room 300, Honolulu, Hawaii 96819 Telephone: (808) 841-6169
Toll Free: 1 (800) 622-3830
Facsimile: (808) 842-4281
SPOUSE / DEPENDENT QUESTIONNAIRE
Please complete this form if you are a new member with a dependent spouse/children. Failure to submit this form may result in a delay of coverage for your dependents.
MEMBER NAME
Date of Birth
Social Security Number
(Last, First, Middle Initial)
FOR H&W FUND OFFICE USE ONLY
NEW
ADD DEPENDENT
/
/
Effective Date
Address
Home Phone
Cell Phone
(Street, City, State, Zip Code)
Member ID#
STAT Date
ELIG Date
(
)
(
)
M-CERT
B-CERT
SSN
DECREE
QMCSO
PAT-AFF
STEP-AFF
DIV-AFF
Effective Date:
MARITAL STATUS:
Single
Married
Divorced
_______/_______/______
Separated
Widowed
REMARKS:
SPOUSE NAME
Date of Birth
Social Security Number
(Last, First, Middle Initial)
/
/
___ SYS36 ____ MED
____ RX ____ DENTAL ___ VISION
DEPENDENT(S) NAME
Gender
Date of Birth
Social Security
Child lives with:
Check all that applies:
Male
You
F/T Student
Stepchild
/
/
Other parent
Disabled
Adopted
Female
Male
You
F/T Student
Stepchild
/
/
Other parent
Disabled
Adopted
Female
You
F/T Student
Stepchild
Male
/
/
Other parent
Disabled
Adopted
Female
Male
You
F/T Student
Stepchild
/
/
Other parent
Disabled
Adopted
Female
You
F/T Student
Stepchild
Male
/
/
Other parent
Disabled
Adopted
Female
Is your spouse currently employed?
No
Yes (If “YES”, please complete this section)
Occupation:
Employment Status (check one):
Full Time
Part-Time (Avg # of hrs/wk _______)
Self-Employed
Employer Name
Address
Telephone
(
)
Does your spouse have health coverage through his/her employer?
Yes
No
Effective Date
/
/
Carrier Name
Group #:
Subscriber #
Coverage Type:
Plan Type:
(List name(s) of all dependents covered under this plan)
Medical
Drug
Dental
Single
Family
_______________________
_______________________
_______________________
Vision
Supplemental
Subscriber & Children
_______________________
_______________________
_______________________
Are any of your dependent children employed 20 or more hours per week?
No
Yes
(If “YES”, please complete this section)
Dependent Name
Avg # of hrs/wk:
Occupation:
Employer Name:
Address
Telephone
(
)
Does dependent have health coverage through his/her employer?
Yes
No
Coverage Type:
Medical
Drug
Dental
Vision
Carrier Name
Policy No.
Subscriber ID#
Effective Date:
/
/
(Please complete and sign the page 2 of this questionnaire)
Page 1 of 2
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