COORDINATION OF BENEFITS
Please print clearly
Dear Performer:

Please complete this form, and the attached questionnaire, and return it to the AGVA Welfare Trust Fund, 363 Seventh Avenue, 17th Floor, NY, NY 10001.
Once these forms have been completed and returned to the Fund office, we will be able to process medical benefits under the AGVA Medical Plan.

PERFORMER’S NAME _____________________________________________________________
PERFORMER’S STAGE NAME (if any)_________________________________________________
ADDRESS_________________________________________________________________________
__________________________________________________________________________________
PHONE______________________________CELL PHONE_________________________________
EMAIL ADDRESS__________________________________________________________________
SOCIAL SECURITY # __ __ __ - __ __ - __ __ __ __ AGVA #______________________________
CURRENT (or last) AGVA EMPLOYER________________________________________________
NAME OF SHOW, ROLE & DATE OF HIRE_____________________________________________

PERFORMER’S SIGNATURE________________________________________________DATE_____/_____/20_____

The trustees of the AGVA Welfare Trust Fund have adopted a coordination of benefits rule (COB).
Please answer the following questions:

Do you have any form of insurance coverage, personally or as a dependent?

YES_____NO______
If you answered YES, please complete the following:

MEDICAL INSURANCE PROVIDED BY OTHER UNIONS:

SAG EFFECTIVE DATE__________________________END DATE (?)_______________________

AFTRA EFFECTIVE DATE________________________END DATE (?)______________________

EQUITY EFFECTIVE DATE_______________________END DATE (?)______________________

OTHER COVERAGE (TYPE & ID #)________________________________________________

EFFECTIVE DATE________________________TERMINATION DATE (if applies)____________

HOSPITALIZATION (TYPE)_______________________________________________________


Any person who knowingly and with intent to injure, defraud or deceive the Fund, files a statement of claim containing any false, incomplete or misleading information, may be guilty of
a criminal act punishable under law, and may be denied benefits.