Dependent Enrollment Form - Active Members Page 2
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2SECTION IV – INFORMATION ABOUT OTHER HEALTH PLAN/INSURANCE COVERAGE
IV(A) – Plans other than the City of New York Health Benefits Program
Do any of your dependents have coverage through another employer or union (This includes other NYC Union Health and Welfare Funds,
but not the City of New York Health Benefits Program)?
Yes
No
If you answered “Yes”, please provide the following information:
Employer/Union Plan Name
Policyholder/Subscriber Name
Coverage Effective Date
Coverage Termination Date (if Applicable)
Policy/Coverage Type
Single
Employee + Spouse
Family
Benefits Provided (Check all that apply)
Medical/Hospital
Prescription Drugs
Dental
Vision
IV(B) – City of New York Health Benefits Program Prescription Drug Rider Information
Are you or any of your dependents enrolled in a prescription drug rider through the City of New York Health
Yes
No
Benefits Program? GHI-CBP and HIP HMO enrollees must check “No”.
IV(C) – Listing of Individuals with other Coverage
Please list all individuals (including yourself) with other coverage
Covered by Another Health
Enrolled in NYC Health Plan
Last Name
First Name
SSN
Date of Birth
Plan?
Prescription Drug Rider?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
SECTION V – DEPENDENT LIFE INSURANCE
Dependent Life Insurance (DLI) pays a benefit to you in the event of the death of one of your dependents ($12,000 for a spouse/domestic
partner or $3,000 for a dependent child.) If you elect DLI, your premium of 47 cents ($0.47) will be deducted from your bi-weekly paycheck
regardless of the number of dependents covered. Please select one option below. DLI must be elected within 31 days of the later of (1) your
appointment date, or (2) when your dependent is acquired (marriage, birth, etc.). If this deadline passes, you must provide evidence of good
health (as required by the insurance carrier, Aetna) for any dependents acquired more than 31 days prior to electing DLI. If you have already
elected DLI for existing dependents, new dependents are automatically covered. If you are unsure whether you have already elected DLI,
please contact the PBA Funds Office at the telephone number above. Dependent children can be covered under DLI until age 19 (25 if
enrolled as a full-time student). Please note that DLI eligibility rules for dependent children are different from those for the Health and
Welfare and Retiree Health and Welfare Funds.
Please select one of the following Options:
I have eligible dependents and elect to enroll in Dependent Life Insurance.
I do not have eligible dependents or decline to elect Dependent Life Insurance.
Signature
I certify that the information in sections I, II and III above is correct. I understand that if I provide incorrect information and that information
results in the Fund making payments that it should not have made, I will be responsible for those payments.
Member’s Signature:
Date:
For Office Use Only
Received
Entered By
Verified By
Information Requested
Rev. 20150827
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