Self-Pay Dependent Coverage Contributions

Self-Pay Dependent Coverage Contribution

Atlanta Plumbers and Steamfitters Fringe Benefit Funds

Welcome Participants of Atlanta Plumbers and Steamfitters Local 72 Fringe Benefit Funds!

Self-Pay Dependent Coverage Contribution

Welcome to Online Payment Services. You are entitled to continue coverage for your dependent(s) by making a timely self-contribution using the form below. Please note that contributions must be made based upon the coverage type you elected during the most recent enrollment period. In order for your payment to be processed as quickly as possible, please complete the below information in its entirety. For questions or assistance please contact the Enrollment Department via email at [email protected] or toll free at (888) 365-0072. Please note our office hours are from 8:00 AM to 5:00 PM EST Monday through Friday.

Member Information

Member First Name*

Member Last Name*

Member UA ID*

Member SSN

Coverage Period*

Please tell us the coverage period you are buying coverage for

From

Coverage Type*

Please select the coverage type you are paying for

Spouse and Children - $30 Per Week

Spouse Only $25 Per Week

All sections and elements marked with an asterisk (*) must be filled out to complete the form/process.

Payment Amount*

The amount due is equal to the weekly coverage amount for the coverage type selected (spouse and/or children) x 5 or 4 weeks.

Please note that a 3% fee will be assessed for all credit card payments to offset the cost to the Fund for providing an online payment option.

Payment Amount $

3% Service Fee:

Total Amount Due:

Card Holder Information*

First Name

Last Name

Street Address

City

State

Zip Code

Phone #

Jan	Feb	Mar
Apr	May	Jun
Jul	Aug	Sep
Oct	Nov	Dec