MEMBER HEALTH APPLICATION FORM
GROUP HEALTH PLAN
TRINIDAD AND TOBAGO INSURANCE LIMITED
I am a member of Transcorp Credit Union:
Credit Union
Name of Member:
Nationality:
Occupation:
Date of Birth:
sex:
male
female
Coverage:
Member Only
Member & One Dependent
Member & Family
Marital Status:
Single
Married
Widowed
Divorced
Address:
Phone Numbers: (H)
Phone Numbers: (m)
Email Address 1:
Email Address 2:
Please provide a copy of any two of the following (National ID, Passport, Driver’s License) together with a copy of a recent utility bill: T&TEC, TSTT, WASA, Cable Bill.
National ID Card:
Passport No:
Driver’s License:
Are you or your spouse covered by any other medical plan? If Yes
Name of Plan/Group
Name of Insurance Company
Member:
Spouse:
Applying for the Coverage option of:
Members up to Age 60
$250,000.00
$500,000.00
$ 1,000,000.00
Members over age 60
$400,000.00
Beneficiary:
Date of Birth:
Relationship:
I hereby apply for registration as a Member of the Credit Union’s Group Health Plan and agree to the payment of the premiums for my continued coverage under the Policy, in accordance with the terms and conditions of the Plan and agree to be bound thereby. I nominate the person named above as beneficiary to receive any amounts which may be payable in the event of my death.
Member’s Signature
Date
MEMBER’S DEPENDENTS TO BE COVERED
Name of Dependent(s):
Relationship
Sex
Date of Birth
TO BE COMPLETED BY CREDIT UNION
Authorized Signature:
Title:
Credit Union Stamp:
date
TO BE COMPLETED BY THE BEACON INSURANCE
Effective Date of Member’s Coverage:
Class/Coverage:
Health Rate:
Policy No. Health:
Cert. No. Health:
Submit