Union - Factory and Group Program

Authorization for PAYROLL Deduction

Please fill out all information as accurately as possible. The information you provided will assist in formulating complete health profile.

Member Information

First Name *

Last Name *

Date of birth *

Marital Status

Email *

Address *

City *

State *

Postal code *

Cell Phone *

EMPLOYEE NUMBER *

PLANT or LOCATION NAME *

Emergency Contact

Emergency Contact Full Name *

Emergency Contact Cell Number *

Emergency Contact Email *

Relationship to Member *

(1) TCT CAREGIVING ANNUITY AGENT WILL CONTACT YOU AFTER YOU SCHEDULE A TIME THROUGH THE CALENDAR BELOW, WITHIN 48-72 HOURS. THIS WILL DEPEND ON AVAILABILITY AND DATES THAT ARE AVAILABLE. (2) AT THE TIME OF YOUR CALL YOU WILL BE PLACED IN THE PLAN THAT YOU QUALIFY FOR OPTIONS 1,2,3 RETIREMENT PROGRAMS.

By checking the box, I authorize TCT CAREGIVING to deduct $49 from my weekly check. This is for the purpose of Payment for my Health and Wealth Annuity Benefit Program.

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