Benefits Update Form

Please complete this form to help us better understand your current coverage.

Download Benefits Update Form(PDF)

Beneficiary Information(Required)

First Name Last Name

Email(Required)

Social Security Information

Does Beneficiary receive Supplemental Security Income (SSI)?(Required)

Yes

Does Beneficiary receive Social Security Disability Insurance (SSDI)?(Required)

Yes

Does Beneficiary receive Medicaid benefits(Required)

Yes

If you are receiving Medicaid, please specify your Medicaid ID number (if available):

Does Beneficiary receive Medicare benefits(Required)

Yes

If you are receiving Medicare, please specify your Medicare ID number (if available):

Additional Information

Are you currently enrolled in any other assistance programs? (e.g., SNAP,Housing Assistance)(Required)

Yes

If yes, please specify:

Is there any other information you would like us to know regarding your benefits or health insurance coverage?

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Member of the Independent Trustee Alliance

Associate Member

The Independent Trustee Alliance is a professional association formed by trustees, fiduciaries and other family consultants who work independently or for family offices.

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Continental Trust

717 Atlantic Avenue Suite 8D Boston, MA 02111

Toll-Free: (888) 241-7534

Direct: (617) 423-9500

Fax: (617) 507-1085

info@continental-trust.com

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Associate Member of ASNP

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