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AMALGAMATED TRANSIT UNION
DIVISION 757
RETIREE HEALTH AND WELFARE PLAN
ENROLLMENT FORM
Please complete and return this form to: ATU Trust Administrator, 29866 Gadotti Dr.
Scappoose, OR 97056
1. NAME: ________________________________________________
2. ADDRESS: _____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
3. PHONE #______________________________________________
4. EMAIL: _______________________________________________
5. SOCIAL SECURITY NUMBER: ____________________________
6. DATE OF BIRTH: ________________________________________
7. SPOUSE NAME: _________________________________________
8. DATE OF BIRTH: ________________________________________
9. SOCIAL SECURITY NUMBER: ____________________________
10. LAST DAY WORKED: ___________________________________
11. PERS RETIREMENT DATE: ______________________________
Please attach a copy of your proof of insurance, such as monthly receipts, a letter from the carrier
and/or a copy of the Social Security letter stating the cost the current Medicare Part B deducted
from your social security benefit.
12. Are you or your spouse covered by any other health insurance (other than Medicare)?
[ ] Yes [ ] No
13. If yes, Name and Address of other Insurance Carrier:
________________________________________________________
________________________________________________________
________________________________________________________
14. Phone Number: ____________________________________________
15. Policy Number: ____________________________________________
16. If no, do you wish to enroll in the Kaiser Permanente Plan? [ ] Yes [ ] No
[ ] I wish to waive participation in the Amalgamated Transit Union, Division 757 Retiree
Health and Welfare Plan currently. I understand that I will only be able to enroll during
open enrollment Oct 15 th thru Dec 7 th each year.
17. If a retiree was employed at C-Tran in a bargaining unit, prior to that bargaining unit joining
the Health and Welfare Trust Fund, at the retirement of that employee, he/she must notify the
Administrator of their choice of benefits, either “years of service” or “years of
contribution/participation.” This shall be a onetime choice.
[ ] I elect to have my benefits calculated on YEARS OF SERVICE
[ ] I elect to have my benefits calculated on YEARS OF CONTRIBUTION/PARTICIPATION
Signature: ______________
Date: _______________________________________