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Reciprocity reciprocal

Uebt 2026

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The document is an Active Enrollment Form for the UFCW & Employers Benefit Trust, which outlines the process for enrolling employees and their dependents in Health & Welfare coverage. It includes instructions for completing the form, necessary documentation for adding or changing dependent coverage, and details about eligibility and plan selection. The form also requires personal information from the participant and their dependents, as well as consent for disclosure of information related to benefits.

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Click ‘Get Form’ to open the uebt in the editor.
Begin with Section 1, COVERAGE SELECTION. Choose your preferred Medical and Dental Plans by checking the appropriate boxes.
In Section 2, PARTICIPANT / EMPLOYEE INFORMATION, fill in your personal details including name, gender, social security number, and contact information.
Proceed to Section 3 for DEPENDENT(S) INFORMATION. Enter details for each dependent you wish to enroll, ensuring all required fields are completed.
In Section 4, BENEFICIARY OF DEATH BENEFIT, specify your beneficiaries by providing their names and relationships. Ensure that the total percentage equals 100%.
Complete Section 5 regarding SPOUSE/DOMESTIC PARTNER EMPLOYMENT AND OTHER INSURANCE. Answer questions about your spouse's employment status and insurance coverage.
Finally, review all sections for accuracy before signing in the certification area at the end of the form.

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