0916 Qualifying Change in Status Request

0916 Qualifying Change in Status Request

Qualifying Change in Status Request

Employee Name: / Employee Number:
Phone Number: / Date of Request:
IMPORTANT: In order to make any revisions to your elected benefits due to a Qualifying Change in Status, you must complete and sign this form and return to Human Resources with applicable documentation within 60 days of the qualifying change. Coverage revisions will become effective on the qualifying event date. If you have questions, please call Human Resources at (239) 424-3500. You may fax the completed form to 424-4082.
SECTION ONE – Status Change:
Check the qualifying event that applies in this section. Complete and attach documentation as noted.
Marriage* – Date of Marriage: (attach copy of marriage certificate)
Divorce* – Date of Divorce: (attach stamped copy of Dissolution of Marriage)
Birth or Adoption of a Child – Date of Birth/Adoption Final (Birth of a child does not require documentation. For adopted child, attach Adoption Decree.)
Gain or Loss of Other Group Health Coverage – Date of gain/loss of coverage (attach Portability Letter or document showing start or end date of coverage)
Child’s Eligibility – Date Child No Longer Meets Eligibility Guidelines
Death of Covered Dependent – Date of Death
Return from Leave of Absence – Date of Return Reenroll for Life Disability?
Qualified Medical Child Support Order – Date of Order: (attach Order)
*If you have legally changed your name, please complete form #2405 “Employee Address and Personal Information Change Request” and provide applicable documentation. Name change is not subject to 60 day limitation.
SECTION TWO – Corresponding Benefit Change:
Check the type of change you are requesting (must be consistent with Section One).
Begincoverage as follows:
Add Employee Coverage:...... Health High PPO Dental PPO Dental Vision
Add Spouse Coverage:...... Health High PPO Dental PPO Dental Vision
Name of Spouse’s Employer:...... Does employer offer health coverage? Yes No
Add Child(ren) Coverage...... Health High PPO Dental PPO Dental Vision
End coverage as follows:
End Employee Coverage:...... Health Dental Vision
End Spouse Coverage:...... Health Dental Vision
End Child(ren) Coverage:...... Health Dental Vision
Dependent Care Spending Account (Pre-Tax Daycare) Name of Daycare:
Current Biweekly Contribution: $ New Contribution: $
Health Spending Account: Current Biweekly Contribution: $ New Contribution: $
SECTION THREE – DEPENDENT INFORMATION:
Provide Name, Date of Birth and SSN for all dependents added in Section Two.
Spouse Name: / Date of Birth: / SSN:
Child Name: / Date of Birth: / SSN:
Male Female Natural Child Stepchild Adopted Child Legal Dependent Grandchild
Child Name: / Date of Birth: / SSN:
Male Female Natural Child Stepchild Adopted Child Legal Dependent Grandchild
Child Name: / Date of Birth: / SSN:
Male Female Natural Child Stepchild Adopted Child Legal Dependent Grandchild
By signing below, I certify that the above information and any attachments are true and correct. I understand that any misrepresentation or falsification will result in penalties and possible termination.
I ATTEST THAT: I DO NOT/have quit using tobacco products -OR- I DO use tobacco products
Employee Signature: DATE/TIME:
Authorized by HR: / Date:

FM# 0916 Rev. 12/11 Page 1 of 1