Get Po Box 1987 Grapevine Tx 76099

ALLIED PILOTS ASSOCIATION ENROLLMENT/CHANGE FORM Return completed form to WEB-TPA P. O. Box 1987 Grapevine TX 76099-1987 1-800-477-8957 Fax 469-417-1979 VOLUNTARY SUPPLEMENTAL MEDICAL CUSTODIAL CARE BENEFIT PLAN SMP Check appropriate box. I Enrollment/Re-enrollment Name Last First Middle Initial I Dependent Change Street Address Employee Number City Date of Birth MO/DAY/ YR / Date of Hire State Zip Code Date of Recall First Name Gender I Married I Single I American Airlines I Staff List any periods of furlough paid or unpaid leave of absence sick personal family leave military leave etc* List dependents to be covered Last Name Telephone Number Status Check one I Active Flight Status I Retired I TAG I LOA I Surviving Spouse I Furlough I Military I SLOA I MDSB Date of Furlough Social Security Number Spouse Dependent Child If you are adding a spouse due to marriage or a dependent due to birth you must attach supporting documents i*e* marriage certificate birth certificate or coverage will NOT go into effect until documentation has been received by WEB-TPA. 1. Are your dependent children covered by the Company s Group Health Plan I Yes I No If no If yes what is lifetime maximum of other coverage If no please explain MONTHLY ACH DEDUCTION Please attach completed ACH Transfer Form* You are responsible for timely payment. If your coverage is cancelled due to non-payment the re-enrollment provisions apply. I certify that the information provided on this form is true and correct and that I am currently Actively at Work and anticipate being Actively at Work when coverage begins. The term Actively at Work means the customary performance of all regular duties of employment on a full time basis and for full pay at the Plan Participant s customary place of employment or at some location at which that employment required him to travel and solely for the purpose of determining eligibility under this Plan Actively at Work shall be deemed to include absences from work due to a health factor as that term is defined in the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated thereunder as the same may be amended from time to time. NOTE You may enroll in SMP if you are on paid sick medical disability or unpaid sick status. I further certify that any Dependent Child I enroll age 19 to age 26 does not have other group health coverage available from his or her employer nor from his or her spouse s employer. If other group health coverage is available such dependent child must enroll in the other group health coverage before enrolling in SMP. I Enrollment/Re-enrollment Name Last First Middle Initial I Dependent Change Street Address Employee Number City Date of Birth MO/DAY/ YR / Date of Hire State Zip Code Date of Recall First Name Gender I Married I Single I American Airlines I Staff List any periods of furlough paid or unpaid leave of absence sick personal family leave military leave etc* List dependents to be covered Last Name Telephone Number Status Check one I Active Flight Status I Retired I TAG I LOA I Surviving Spouse I Furlough I Military I SLOA I MDSB Date of Furlough Social Security Number Spouse Dependent Child If you are adding a spouse due to marriage or a dependent due to birth you must attach supporting documents i*e* marriage certificate birth certificate or coverage will NOT go into effect until documentation has been received by WEB-TPA. 1. Are your dependent children covered by the Company s Group Health Plan I Yes I No If no If yes what is lifetime maximum of other coverage If no please explain MONTHLY ACH DEDUCTION Please attach completed ACH Transfer Form* You are responsible for timely payment.