Application Information for Member

Questions during enrollment?
Call Kocher Insurance Group at 888-212-7822.

Active Members that are available to work are eligible to elect these benefits. Currently retired members are not eligible to elect these benefits.

Before You Begin

To complete your application, please have the following ready:

Social Security Numbers (SSNs) for yourself and anyone you’re covering (i.e. a spouse or children)
Banking account info for payments (routing and account numbers for ACH)
Names and contact info for your beneficiary or beneficiaries (those who would receive a benefit if something happens to you)

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First Name *

Middle Name

Last Name *

Suffix

Address Line 1 *

Address Line 2

City *

State *

Postal Code *

Home/Cell Phone *

Work Phone

Email *

Email Confirmation *

Gender *

Male
Female

Date Of Birth *

State Of Birth *

Social Security Number *

What is your preferred method of communication? *

* INDICATES required FIELDS

By continuing with this application, you are stating that you understand that by electing this coverage, you must remain a dues-paying member of the union to maintain coverage.

Insurance coverage is provided under the terms of a group life insurance policy, Group Policy #70696-5-6, issued and delivered in the state of Illinois to National Coalition of Labor – Chicago Laborers District Council as the policyholder. The group life insurance policy is issued by ReliaStar Life Insurance Company, Minneapolis, Minnesota. Coverage may not be available in all states. Contact Kocher Insurance Group at 888-212-7822 for further details. Policy form ICC LP14GP or LP00GP (may vary by state).