Spouse/dependent Questionnaire - Hawaii Electricians Health & Welfare Fund Page 2

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DEPENDENT CHILDREN/STEPCHILDREN COVERAGE

If any of your dependents are from a previous marriage, born out of wedlock or stepchild(ren), please complete the following:

Name of dependent child(ren):

Are any of the dependent children covered for health benefits under the other biological parent?

Yes

Effective Date:

Name of the other biological parent:

Date of Birth:

Carrier Name:

Policy No:

Subscriber ID#:

If you are divorced, check one of the following:

Divorce decree stipulates the other parent must provide benefits

Divorce decree stipulates joint custody

Decree does not stipulate special provisions

Name of custodial parent:

Mailing Address:

If you have a court order to provide medical coverage for any of the dependent children, please complete the following:

Date of Order:

Effective Date:

Child Name:

Custodian Name:

Mailing Address:

(Attach copy of divorce decree and/or court order)

MEDICARE COVERAGE

Are you or any of your dependents enrolled in Medicare?

Yes

(If “YES”, please complete the following):

Name of person eligible for Medicare:

Medicare No.

Reason for Medicare:

Age 65 or older

Disability due to _________________________

ESRD / Date Dialysis Treatment Began: ____/____/____

Type of Coverage:

Part A (Hospital)

(_____/_____/_____)

Part B (Medical)

(_____/_____/_____)

Part D (Drug)

(_____/_____/_____)

(Attach a copy of your Medicare Card)

OTHER HEALTH CARE COVERAGE

Do you or your dependents have any other coverage (i.e., previous employer, TRI-CARE)?

Yes

(If “YES”, please complete the following)

Subscriber Name:

Subscriber ID #:

Effective Date:

Carrier Name:

Policyholder:

Group No:

Medical

Drug

Dental

Vision

Supplemental

Plan Type:

Single

Family

Subscriber & Spouse

Retiree

Coverage Type:

I/We understand that the Fund is relying on this information to determine eligibility for medical benefits for myself and my dependents. I/We understand that it is unlawful for me to

make any statements which I/we know is untrue, false or misleading. I/We declare and affirm in good faith and under perjury under Federal and State laws that the information

provided herein in true and correct to the best of my knowledge and I/We consent to the provisions stated above on this form which I/We have read and fully understand. I/We also

understand that the penalty for committing perjury may be a fine or imprisonment, or both, and may also result in a legal claim against me for recovery or offset of benefits improperly

paid to be or my dependents based on the information provided herein.

Member Signature

Date

Spouse Signature

Date

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