Please complete this form in its entirety, front and back and return it in the enclosed envelope. The information requested below is very important as it provides the Fund office with current information about you and your dependents. Please only list those dependents who meet the definition of an Eligible Dependent, as that term is defined in your Summary Plan Description. This form also allows you to designate a beneficiary for the purpose of receiving benefits from the Fund upon your death. Please sign and date the form.

The “Patient Protection and Affordable Care Act”, a health care reform bill enacted by Congress and signed into law by the President in March 2010, provides that group health plans that cover dependent children must extend coverage for such dependents until attainment of age 26. In addition, a dependent child may not be excluded based on the following criteria: financial dependency, residency, student status, marital status, employment or eligibility for other coverage. By completing and signing this form, you are certifying that you wish to apply for coverage for the dependents named below.