Fillable 480 Eligibility International Changeof Address V03

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480 Eligibility International Changeof Address V03

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The 480 Eligibility International Changeof Address V03 form is 1 page long and contains:

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INTERNATIONAL CHANGE OF ADDRESS FORM
Return this Form to: MPI P.O. Box 1999 Studio City, CA 91614-0999
Toll Free: (855) 275-4674 Fax: (818) 766-1229 Email: service@mpiphp.org
Please Select One
Name
MPID / SSN
Date of Birth
New Address Effective Date
City
State / Province
Zip /
Postal Code
Email
Phone
Fax
* If you would like personal health information to be sent to someone other than yourself, you need to complete an Authorization for Release of Health
Information Form. If you are requesting the release of your Health and/or Pension information to a person with a Power of Attorney, Conservator or
any third party, you must have the required legal documentation on file with MPI. Additional information and required forms for releasing your Health
and Pension information may be found at www.mpiphp.org.
DEPENDENT/BENEFICIARY ADDRESS CHANGE INFORMATION (This form cannot be used to designate new beneficiaries)
Name
MPID / SSN
Date of Birth
New Address
Effective Date
City
CountryZip / Postal Code
Email
Phone
Name
MPID / SSN
Date of Birth
New Address
Effective Date
City
Country
Zip /
Postal Code
Email
Phone
Name
MPID / SSN
Date of Birth
New Address
Effective Date
City
Country
Zip / Postal Code
Email
Phone
I understand that the information I provided above will be used to update my records for both the Motion Picture Industry (“MPI”) Pension and Health
Plans. I must provide separate notification to all Employers, Local Unions and Credit Unions. I further understand that I must submit this form to MPI at
the address above each time this information changes to ensure I receive Plan information. My signature is provided below to validate the information
on this form.
Date
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Country
State / Province
State / Province
State / Province
Form: 480_V03
Apartment / Unit
Apartment / Unit
Apartment / Unit
Apartment / Unit
RETIREE/SURVIVOR ADDRESS CHANGE INFORMATION
Participant
Retiree/Survivor
Spouse
Child
Beneficiary
Same as the Retiree/Survivor Address Above
Same as the Retiree/Survivor Address Above
Same as the Retiree/Survivor Address Above
Retiree/Survivor Consent
Retiree/Survivor Signature
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480 Eligibility International Changeof Address V03

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Completed 18 July 2020

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