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Please complete the form and return with all necessary documentation.

As long as you get all documents and enrollment form back to be by tomorrow, I can add your
spouse effective 10/1/2023. I can’t add her any sooner.

Karen Jeske
Wilson-McShane Corporation
1431 Opus Place, Suite 350
Downers Grove, IL 60515
Toll Free: 866-844-0488
Local: 630-288-6868
Fax: 630-686-4128

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DEPENDENT ENROLLMENT AND CERTIFICATION FORM

Please complete and return this Dependent Enrollment and Certification Form to: Fund Administrator,
S.E.I.U. Local No. 1 Health Fund, 1431 Opus Place, Suite 350, Downers Grove, Illinois 60515. You must provide
copies of birth certificates for all dependent children a arria e erti i ate r rs se l s e additi al
re ired d e t t eri de e de t eli ibilit see De i iti li ible De e de ts a d e ired D e t
r Claims will not be paid until the Fund Office has a birth certificate on file.
EMPLOYEE INFORMATION
Employee Name Sex Date o Birth Social Securit ber Home Telephone
ast: MI: First: M
I I ( )
F

Employee Home Address

treet t City State Zip

aili ddress i Di ere t r e ddress

treet t City Stat e Zip