CHANGE OF ADDRESS FORM

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: [email protected]
PARTICIPANT ADDRESS CHANGE INFORMATION
Please Select One
Participant
Retiree/Survivor
Spouse
Child
Address Type
Physical
Mailing
Third Party* Type:
Name
MPID / SSN
Date of Birth
New Address
Effective Date(s)
City
State
Zip
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. 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
New Address
MPID / SSN
Same as Participant’s Above
City
Zip
Email
Name
Phone
MPID / SSN
Date of Birth
Same as Participant’s Above
City
Effective Date(s)
State
Relationship
Zip
Email
Name
New Address
Effective Date(s)
State
Relationship
New Address
Date of Birth
Phone
MPID / SSN
Date of Birth
Same as Participant’s Above
City
Relationship
Effective Date(s)
State
Zip
Email
Phone
PARTICIPANT’S CONSENT
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 the
address above each time this information changes to ensure I receive Plan information. My signature is required to validate the information on
this form.
Participant’s Signature
Date
If you would like to receive MPI Publications via email, please log-in to your MPI account at www.mpiphp.org and complete the “Go Green”
process.