Forms

 

Listed below are some important forms within our office and how to add and remove dependents from insurance.

Documentation needed to add/remove dependents:

To add a spouse-

  • Copy of Marriage certificate & new Iowa Laborer’s Health & Welfare Plan enrollment form.
  • Statement of “loss of coverage” & new enrollment forms

 

To add a new baby/adopted child-

  • New enrollment forms, copy of social security card, copy of birth certificate.
  • New enrollment forms & signed, dated copy of the adoption papers & copies of the new birth certificates.

 

To add a child-

  • Copy of the child’s birth certificate; if you are not listed on the birth certificate as the child’s father/mother, then we will also need a court order establishing paternity or something from the state showing payment of child support.

 

To add a step-child-

  • New enrollment forms.
  • Copy of the most recent tax statement naming the child as a dependent.
  • Notarized statement signed by the participant and their spouse stating that the child is a) living with the participant in a regular parent/child relationship; b) that you contribute more that 50% toward the maintenance and support of the said child; c) the child is neither covered nor required to be covered by any other health plan or person.

 

To term/delete a dependent-

  • New enrollment forms.
  • Signed & dated copy of a divorce decree or
  • Letter of credible coverage or
  • Copy of death certificate.

 

If you have any questions on how to fill out the forms, please call 319-366-0859.

Please mail all forms to the Hall at 5000 J Street SW Cedar Rapids, IA 52404. We can forward them to the appropriate parties from there.

 

Vision Claim Form

HRA Payment Request Form

Iowa Laborer’s Health & Welfare Plan add form

The Laborers’ Code of Performance

Skill Sheet

Laborers’ Local 43 Referral Rules as of 2020

Reciprocity Form