Family Status Certificate - PDF by btb19327

VIEWS: 1,254 PAGES: 2

Family Status Certificate document sample

More Info
									FAMILY STATUS CHANGE                                               (BOP USE ONLY) Remarks: _________________________
PMB 0141-1                                                         _________________________________________________
Bureau of Personnel                                                _________________________________________________
500 East Capitol Avenue                                           (PO USE ONLY) Pay Cycle: 12 24 Remarks: _________
Pierre, SD 57501-5070                                              _________________________________________________
Phone: (605) 773-3148                                              Employee Number: ________________________________
Fax: (605) 773-4344                                                PO Initials: ___________ Agency: ___________________

    PLEASE COMPLETE THIS FORM AND RETURN IT TO YOUR HUMAN RESOURCE OFFICE WITHIN 90 DAYS OF THE
                                QUALIFYING CHANGE IN FAMILY STATUS.

Employee Name: _____________________________________ SSN: _____/______/_____ Date of Birth: ____/____/____
                  Last          First           MI   Alternate ID# __________________      Month Day Year

Address: ________________________________________________________________ Date of Marriage: ____/____/____
             Street                        City                State            Zip Code                          Month Day Year

Work Phone: __________________ Home Phone: ___________________ Is your spouse a state employee? ___Yes ___No

Check all that apply:
        I previously made application to add myself and/or dependent(s) to the State’s Health Plan and was denied coverage for a
        an 18-month waiting period. The waiting period will be satisfied on _____________ and I am reapplying for coverage at
        this time.                                                              (date)
        I have not incurred a bonafide family status change event but wish to make application for myself and/or dependent(s) as
        late entrants and begin the 18-month waiting period.
        I authorize the Bureau of Personnel to deduct money from my warrant to make elected health and/or flexible benefits
        effective the date of the qualifying event. Circle the coverage (health and/or flexible benefits) you want to backup.
        Flexible benefits include the dental plan, vision plan, major injury plan, hospital indemnity plan, daycare spending account
        and the medical spending account. All affected flexible benefits will be backed up, if flexible benefits is circled.
        I do not authorize additional deductions from my warrant and realize elected health and/or flexible benefits changes will
        not be effective on the date of the qualifying event. Premiums are paid in advance and the effective date is determined by
        the pay period in which the premiums withheld.
In the last 90 days I have incurred a Family Status Change as defined below and therefore wish to change my benefits.
All of the correct details are listed within this form. The required documentation that substantiates this change in
coverage(s) is either attached to this form, or will be forwarded in a timely manner.

EVENT                                             DATE (MONTH/DAY/YEAR)                    REQUIRED DOCUMENTATION
_______ Marriage                         __________________________________                Copy of marriage certificate
_______ Divorce                          __________________________________                Copy of divorce decree
_______ Birth/Pending Birth              __________________________________                Copy of birth certificate or note from
                                                                                           doctor with expected date of birth
_______ Death                            __________________________________                Copy of death certificate
_______ Adoption                         __________________________________                Copy of judgment of adoption
_______ Loss of Coverage                 __________________________________                Letter from employer which shows
        (Beginning or Ending                                                               reason for loss of coverage including
        Employment)                                                                        termination date of coverage and/or
                                                                                           effective day of coverage

_______ Eligibility of Dependent         __________________________________                Student Status – letter from school
_______ Ineligibility of Dependent       __________________________________                Age - birth certificate
                                                                                           Marriage - copy of dependent’s
                                                                                           marriage certificate
.                                                                                          Student Status – letter from school
                                                                                           Military Enlistment – enlistment papers
_______Change in Day Care Provider       __________________________________                Letter with day care provider or rate
       or a Significant Change in                                                          change or written statement regarding
       Cost or Coverage, or Change                                                         change in care needed
       In Amount of Care Needed
Family Status Change Form                                                                                              07/05
Please supply the following information for those family members who will be affected by this family status event.

         Dependent Name                Relationship       Social Security Number            Date of Birth            Sex (M/F)




Describe who will be affected by this Family Status Change and how you wish to change your benefits. Keep in mind that changes
to your benefit plans must be consistent with the qualified Family Status Change.
Will this change affect:
The Health Plan? If so, how? ______________________________________________________________________________

If you are adding yourself or a dependent(s) to the State's Health Plan, use the space below to fully explain why you
initially declined health coverage under the State's Health Plan. FAILURE TO COMPLETE THIS SECTION WILL VOID
YOUR APPLICATION. Please note that an 18-month waiting period may apply. Refer to the online Summary Plan
Description Document for additional information.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

The Dental Care Plan? If so, how? _________________________________________________________________________

The Vision Care Plan? If so, how? _________________________________________________________________________

The Major Injury Protection Plan? If so, how? _______________________________________________________________

The Hospital Indemnity Plan? If so, how? __________________________________________________________________

The Short-Term Disability Plan? If so, how? ________________________________________________________________

The Medical Expense Spending Account? If so, how? ____________________________________________________
Please indicate the per pay period amount you would like deducted from each paycheck.

The Dependent Day Care Spending Account? If so, how? ____________________________________________________
Please indicate the per pay period amount you would like deducted from each paycheck.


Tobacco Use Election To ensure that the right contribution rates are deducted for your health care coverage during the plan
year we must have your tobacco use election on file. This will help ensure proper payment of any health or life benefits to which
you are entitled. Please select the answer that best applies. Select one answer from each column (if applicable).

                I am not a tobacco user                          My covered spouse is not a tobacco user

                I am a tobacco user                              My covered spouse is a tobacco user


I represent that the foregoing information is, to the best of my knowledge and belief, accurate. I agree that to
retain coverage, I (we) must abide by the Plan’s provisions. Note: As we do with other managed care
provisions, the State reserves the right to verify the information on this application. You could face
disciplinary action and the reduction or loss of your health and life benefits if you misrepresent the
information on this application.

______________________________________________________ _______________________________
Employee Signature                                                                                 Date Signed


Family Status Change Form                                                                                            07/05

								
To top