Loading
Form preview picture

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.

How It Works

tx rating
4.8Satisfied
46 votes

How to fill out and sign portability online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The times of frightening complex tax and legal documents have ended. With US Legal Forms the entire process of completing legal documents is anxiety-free. A powerhouse editor is already close at hand supplying you with various advantageous tools for filling out a Po Box 1987 Grapevine Tx 76099. These guidelines, along with the editor will assist you with the whole process.

  1. Click on the Get Form button to begin enhancing.
  2. Switch on the Wizard mode on the top toolbar to get extra pieces of advice.
  3. Fill out each fillable field.
  4. Ensure the details you add to the Po Box 1987 Grapevine Tx 76099 is updated and correct.
  5. Include the date to the template using the Date function.
  6. Select the Sign tool and make an e-signature. You can use three options; typing, drawing, or uploading one.
  7. Double-check every field has been filled in correctly.
  8. Select Done in the top right corne to save and send or download the sample. There are several choices for receiving the doc. As an instant download, an attachment in an email or through the mail as a hard copy.

We make completing any Po Box 1987 Grapevine Tx 76099 much easier. Use it now!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.