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Motion Picture Industry Pension & Health Plans

Motion Picture Industry Pension & Health Plans 2026

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The document is a form used by the Motion Picture Industry Health Plan (MPIHP) to coordinate health benefits for participants' spouses and dependents. It requires personal information from the participant and their spouse, along with a declaration regarding the spouse's employment status and eligibility for employer-sponsored health insurance. The form must be completed accurately and submitted within 30 days of any changes to ensure proper benefit coordination.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Participant's information, including last name, first name, middle name, date of birth, social security number or MPI ID, and contact details.
Next, provide your spouse's information in the designated fields: last name, first name, middle name, gender, and date of birth.
Carefully read and complete the declaration section. Ensure you check all applicable statements regarding your spouse's employment status and health insurance eligibility.
Sign and date the form at the bottom. Remember that an incomplete form will be returned.
Submit the completed form via email or fax as indicated. Alternatively, you can print it for mailing.

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