Health Care Eligibility Change Form

The following form is used if you need to update your information due to a change in martial status, birth or adoption of a child or other qualifying life event. 

Please remember to update new information, such as name changes, telephone number changes and address changes with the Union Hall. 

If you have questions regarding the Health Care Eligibility Form or supporting documentation needed, please contact Bill Richardson, Julie Steiner or Steve Dujmovich on the Benefits Committee at the Union Hall to assist you. (219) 762-6787. 

For a printable copy of this form, please click on the PDF link below.