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Document on Subject : "EMAIL ADDRESS EMAIL ADDRESS TELEPHONE NUMBER BIRTH DATE NAME (FIRST, I"— Transcript:

1 EMAIL ADDRESS EMAIL ADDRESS TELEPHONE NU
EMAIL ADDRESS EMAIL ADDRESS TELEPHONE NUMBER BIRTH DATE NAME (FIRST, INITIAL, LAST) DATE OF MARRIAGE MARITAL STATUS BIRTH DATE STATE STREET ADDRESS OR P.O. BOX LAST NAME FIRST NAME INITIAL LOCAL UNION NATIONAL AUTOMATIC SPRINKLER INDUSTRYWELFARE FUND HEALTH COVERAGE ENROLLMENT FORM EMPLOYEE/PARTICIPANT INFORMATION SOCIAL SECURITY NUMBER CITY MALE FEMALE HOME PHONE SPOUSE INFORMATION (IF NONE, SKIP TO NEXT SECTION) SOCIAL SECURITY NO. OR HICN DEPENDENT CHILDREN INFORMATION (IF NONE, SKIP TO SIGNATURE SECTION) NAMES (FIRST, INITIAL LAST) SOCIAL SECURITY NO. OR HICN RELATIONSHIP BIRTH DATE YOUR HEALTH BENEFITS COVERAGE IS PROVIDED BY THE NASI WELFARE FUND. A PLAN BOOKLET IS AVAILABLE FROM THE FUND OFFICE OR YOU CAN DOWNLOAD A COPY OF THE PLAN BOOKLET FROM THE FUNDS WEBSITE HTTP://WWW.NASIFUND.ORG. YOU SHOULD EMPLOYEE/PARTICIPANT SIGNATURE DATE CELL PHONE