Health and Welfare

Please fill this out:








_______________________________________DEPENDENTS___________________________________________




Dependent #1


If under age 26 and employed Did employer offer insurance?


Is dependent covered by other insurance?


Dependent #2


If under age 26 and employed Did employer offer insurance?


Is dependent covered by other insurance?


Dependent #3


If under age 26 and employed Did employer offer insurance?


Is dependent covered by other insurance?


Dependent #4


If under age 26 and employed Did employer offer insurance?


Is dependent covered by other insurance?


Dependent #5


If under age 26 and employed Did employer offer insurance?


Is dependent covered by other insurance?




If a dependent is under age 26 and is employed and is OFFERED health insurance through that employer, than that dependent is not eligible for coverage under the Steubenville Electrical Welfare Fund.

PLEASE NOTE: It is VERY IMPORTANT that you notify the Fund of any change in dependents or change in address. Failure to do so will cause delay in payment of your insurance claims.

If any answer to “Is dependent covered by other insurance?” is yes, then please fill out the next form (Medicare Information) and submit it.

WARNING: Any person who, with intent to defraud of knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. (Ohio Revised Code Section 3999.21)

MEDICARE INFORMATION

If Medicare covers you or a member of your family, please complete this section.


The following information can be found on your Health Insurance card from Medicare:




OTHER INSURANCE CARRIER INFORMATION












If other insurance is family coverage, please list names, birthdates and relationship of those covered under this policy and submit the form. If there is a court order designating responsibility for a child’s health care, please attach a digital copy to this form.