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  • RTD/ATU 1001 Health & Welfare Trust 2019 Waiver
    RTD/ATU 1001
    HEALTH AND WELFARE TRUST
    2821 South Parker Road
    Suite 215
    Aurora, Colorado 80014
    (303) 745-7004

    CLAIM FORM 2019
    Complete the form in its entirety. Only one claim form is required per family per calendar year.

    PARTICIPANT STATEMENT
    Name:  
    Address:
    Apt. Number:
    City, State: ,
    Zip Code:
    Social Security Number:
    Date of Birth:
    Marital Status:
    Sex:
    Employed By:
    Email:
    (Note: A copy of this form will be emailed to the email address you provide)
    SPOUSAL INFORMATION
    Spouse Name:
    Spouse SSN:
    Spouse Birthdate:
    Spouse Employment: Employed     Not Employed
    If Employed, please provide the following:
    Spouse Employer Name:
    Spouse Employer Address:
    Spouse Employer Suite Number:
    Spouse Employer City, State: ,
    Spouse Employer Zip Code:
    Spouse Employer Telephone Number:

    ARE YOU OR YOUR DEPENDENT(S) INSURED UNDER ANY OTHER GROUP INSURANCE OR GOVERNMENT PLAN WHICH WILL ALSO PAY FOR MEDICAL EXPENSES? IF YES, PLEASE PROVIDE THE FOLLOWING:
    Name of Insured:
    Name of Insurance:
    Policy Number:
    Address of Plan:
    Suite Number of Plan:
    Plan City, State: ,
    Plan Zip Code:
    Plan Telephone Number (including Area Code):
    I/We jointly certify that the above information is true and correct. I/We hereby authorize all doctors, hospitals, pharmacists or other institutions rendering care and treatment to furnish the RTD/ATU 1001 Health and Welfare Trust full information regarding treatment rendered (including copies of their records). I/We also authorize any Union Trust Fund Employer or Insurance Carrier to furnish the RTD/ATU 1001 Health and Welfare Trust information regarding benefits to which I/we may be entitled. A photostatic copy of this authorization shall be considered as effective and valid as the original. 
    Employee Signature:
    Date:
    Spouse Signature:
    Date:


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