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Chicago Laborers Welfare Plan 11465 W. CERMAV Road, Westchester, IL 60154 708-562-0200 or 866-906-0200 ENROLLMENT FOR INDIVIDUALS WHO REACHED LIFETIME LIMIT If you or your dependents have lost coverage
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How to fill out this special enrollment form:

01
Start by carefully reading all instructions provided with the form.
02
Gather all necessary supporting documents and information, such as personal identification, contact details, and relevant healthcare coverage information.
03
Begin filling out the form by entering your personal details, such as name, address, and date of birth, as instructed.
04
Provide accurate and up-to-date information regarding your current healthcare coverage, if applicable.
05
Answer all questions on the form truthfully and to the best of your knowledge.
06
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Sign and date the form where indicated.
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Submit the form as instructed, either by mail or electronically, depending on the specified method.

Who needs this special enrollment form:

01
Individuals who have experienced a qualifying life event, such as marriage, birth or adoption of a child, loss of other healthcare coverage, or a change in residence.
02
Those who are seeking to make changes to their current healthcare coverage during a special enrollment period.
03
Individuals who are eligible for a special enrollment period due to certain circumstances, such as aging off their parent's health insurance plan or being denied coverage through Medicaid or the Children's Health Insurance Program (CHIP).
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This special enrollment form is a document used by individuals to apply for health insurance outside of the normal enrollment period.
Individuals who experience a qualifying life event, such as losing other health coverage, getting married, having a baby, or moving to a new area, are required to file this form.
To fill out this form, individuals need to provide personal information, details about the qualifying life event, and any supporting documentation as required.
The purpose of this form is to allow individuals to enroll in a health insurance plan outside of the normal enrollment period due to a qualifying life event.
Information such as personal details, qualifying life event details, income information, and any supporting documentation may need to be reported on this form.
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