PARI-MUTUEL EMPLOYEES GUILD
of
- GENERAL
OFFICE -
(626) 301-7900
- FAX (626) 301-7960
_________________________________________________________________
ONE-TIME HEALTH/WELFARE COVERAGE
APPLICATION
FORM DUE TO DISABILITY
This form must be submitted
by claimant to the Union Secretary/Treasurer with substantiated written
documentation
from attending
Physician. This request will then be
submitted for approval to the Pari-Mutuel Employees Guild of
California, SEIU Local 280 Health/Welfare
Trustees.
Print
Name___________________________________________________________________
(Last)
(First)
(Middle)
Mailing
Address_______________________________________________________________
Social Security No. _____- ____- _____ Birth Date ___/___/___ Male ___ Female ___
Phone Number (Home) (___) _________ Phone Number (Other) (___) __________________
Disability Information:
Date Disability Started ________________ Date
Released from Disability __________________
Doctors Name ________________________________________
Telephone # (___) __________
Address
_____________________________________________________________________
I hereby
certify that the foregoing answers, declarations & attachments are true
& correct.
__________________________________ ___________________________
Members
Signature Date
------------------------------------------------------------------------------------------------------------------
- OFFICE USE
ONLY -
Date Received _______________________ Date submitted to
Trustees __________________
Approved _____ Rejected _____ Pending _____
------------------------------------------------------------------------------------------------------------------
cc:
R.A. Hughes
Claimant (Member)