Dependent Enrollment Form - Active Members
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1
2Health and Welfare Fund
Patrolmen’s Benevolent Association of the City of New York
th
125 Broad Street – 11
Floor, New York, NY 10004
212-349-7560
Dependent Enrollment Form – Active Members
SECTION I - MEMBER INFORMATION
Social Security Number
Last Name
First Name
Middle Initial
Gender
Marital Status
Date of Birth (MM/DD/YYYY)
Tax Registry No.
Male
Single
Married
Divorced
Widowed
/
/
Female
Legally Separated
Domestic Partner
Home Address Line 1
Home Address Line 2
City
State
Zip Code
E-mail Address
Home Telephone Number
Mobile Telephone Number
Command
SECTION II – ADD NEW DEPENDENTS
Date of
Medicare
Relationship
Last Name
First Name
SSN
Gender Disabled?*
Birth
Eligible?
Spouse
Male
Yes
Yes
Female
No
No
Domestic Partner
Dependent Child
Spouse
Male
Yes
Yes
Domestic Partner
Female
No
No
Dependent Child
Spouse
Male
Yes
Yes
Domestic Partner
Female
No
No
Dependent Child
Spouse
Male
Yes
Yes
Domestic Partner
Female
No
No
Dependent Child
Please Note: When adding or removing a dependent you must provide the applicable documentation (e.g., birth certificate, marriage
certificate or copy of divorce decree).
SECTION III – DROP EXISTING DEPENDENTS
Reason
Last Name
First Name
SSN
Date of Birth
Divorce
Death
Loss of Dependent Child Status
I wish to voluntarily drop eligible dependent
Other
Divorce
Death
Loss of Dependent Child Status
I wish to voluntarily drop eligible dependent
Other
Divorce
Death
Loss of Dependent Child Status
I wish to voluntarily drop eligible dependent
Other
*Dependent children may be covered beyond the age of 26 if they are: (1) unmarried; and (2) unable to support himself/herself due to a physical
or intellectual disability or mental illness that occurred prior to age twenty-six (26); and (3) enrolled as a disabled child in the City of New York Health
Benefits Program.
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