Enrollment Change Form
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1ENROLLMENT CHANGE FORM
WELFARE FUND BENEFITS OFFICE • UFCW LOCAL 655
13537 Barrett Parkway Drive, Suite 100 – Manchester, Missouri 63021 – (314) 835-2700 (in St. Louis) or (866) 565-2700 (outside St. Louis)
Instructions:
If you have experienced a life changing event which allows you to modify your original enrollment election,
please complete this form and submit any documentation needed to the Fund Office within 31 days of the
event.
If you elect benefits, sections I, II, III, IV, and V must be completed and signed and returned to the Fund office.
If you decline benefits, check the appropriate box in section I, sign and date the form, and submit to the Fund office
I. Enrollment Election (Check the appropriate Box)
I Elect benefits for the following family members:
• Employee only
• Employee & Spouse
• Employee and *Child(ren)
• Employee and *Family
*Step-Children must live with the Employee to be eligible for enrollment
Important Notice: Mid-year changes are not permissible, except in the case of a Life-Changing Event.
If an active enrollee is eligible for Medicare, the Fund is the primary insurance carrier, unless COBRA coverage is purchased.
• *I decline all Health & Welfare benefits
*I, ______________________________, understand by declining coverage, I will not be eligible for benefits
(Print name of employee)
until the next annual open enrollment period, (unless a life changing event occurs).
(Signature below required)
_________________________________________________________________________________
Signature of Employee Declining Coverage
Date
II. Participant Information
Name: ______________________________________________________________________________________________
Last Name
First Name
Middle Initial
Policy Holder’s ID No. or Social Security No.: ______________________________________
Gender: • Male • Female
Address: _____________________________________________________________________________________________
City: ___________________________________________ State: _____________ Zip Code: _________________________
Phone Number: _____________________________________________
Birth Date: _____ / _____ / _____
Month
Day
Year
III. Spouse Information:
Spouse’s Name: _______________________________________________________________________________________
Last Name
First Name
Middle Initial
Gender:
• Male
• Female
Birth Date: ____ / ______ / _____ Social Security No.:__________________________
IV. Print Name of Each Dependent Below (if electing dependent coverage)
Last Name
First Name
Middle Initial
Birth Date
Social Security Number
Gender
Child-1 _____________________________________________
___ / ___ / ___
_____________ • Male • Female
Child-2 _____________________________________________
___ / ___ / ___
_____________ • Male • Female
Child-3 _____________________________________________
___ / ___ / ___
_____________ • Male • Female
Child-4 _____________________________________________
___ / ___ / ___
_____________ • Male • Female
Child-5 _____________________________________________
___ / ___ / ___
_____________ • Male • Female
V. Payroll Deduction Authorization
I hereby apply for Health & Welfare benefits provided by UFCW Local 655 Welfare Fund for myself and for the eligible dependents
listed on this form. I understand that I have made an election to enroll for benefits for the Plan Year indicated on this Enrollment
Form. Any choice I have made may only be altered as the result of a life-changing event. I declare for myself and/or my dependent(s)
that I am eligible to enroll in this plan and request to be covered. I authorize my employer to deduct contributions from my pay.
Should changes take place affecting these statements, I will immediately inform the Welfare Fund of the change.
Signature of Employee Electing Coverage
Date
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