Local 810. New York City

United wire, metal & machine health & welfare fund. Pension fund.

Entered by: Date:

Full Name: Sex: Male: Female:

Address:

Street Nº. City. State.

Home Phone Nº. E-mail Address.

Social Security Nº. Date of birth.

Name your present company/shop.

Date you first became employed by present company/shop.

Were you ever employed by another company/shop having a collective bargainig agreement with Local 810? Yes No

If “Yes”, give the name of the company/shop and the date you first became employed by it.
Name of company/shop Date employed

Is your spouse covered by any other health insurance plan? Yes No

Name of Plan.

I hereby designate as my beneficiary(ies) to recieve the amount of benefits, if any, payable on my death from the United Wire, Metal & Machine Health & Welfare and/or Pension Fund, revoking all prior designations:

Name of beneficiary(ies) Relationship.

Address.

If more than one beneficiary is named, the death benefits will be paid in equal shares to the designated beneficiaries who survive the employee. If no such beneficiary survives, payment will be made in accordance with rules adopted bt the Trustees.

List below name of spouse and unmarried dependent children.

Full name. Social Security # Relationship. Date of birth.

If you are declining enrollement for yourself or your dependents (incluiding your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan at any time. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents at any time.

Employee signature. Date.

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