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Health Care Benefits Change Form Add Dependents* Change IRS Tax Status of Dependent(s) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last Name (Please Print)First NameEmployee NumberDepartment FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Home Address - StreetCityStateZipDaytime Phone numberAdd Spouse/Domestic PartnerAdd to FORMCHECKBOX Medical FORMCHECKBOX Dental FORMCHECKBOX VisionEffective Date: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameMISocial Security NumberDate of birthRelationship FORMCHECKBOX Spouse FORMCHECKBOX Male my IRS tax dependent FORMCHECKBOX Domestic Partner FORMCHECKBOX Female FORMCHECKBOX Yes FORMCHECKBOX No Reason FORMCHECKBOX New spouse/domestic partner (attach Affidavit of Marriage/Domestic Partnership) FORMCHECKBOX COBRA Coverage ended FORMCHECKBOX Lost eligibility for other medical coverage (attach proof of other coverage) FORMCHECKBOX Change in IRS Tax Status FORMCHECKBOX Yes Now my IRS tax dependent. FORMCHECKBOX NoAdd Dependent Child(ren) Add to FORMCHECKBOX Medical FORMCHECKBOX Dental FORMCHECKBOX VisionEffective Date: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameMISocial Security NumberDate of birthRelationshipEmployee’s DependentORPartner’s DependentOROther (Step-child or Legal Guardian) FORMCHECKBOX Son FORMCHECKBOX Daughter FORMCHECKBOX Son FORMCHECKBOX Daughter FORMCHECKBOX Male FORMCHECKBOX FemaleReason FORMCHECKBOX Birth/Adoption FORMCHECKBOX Court order/legal guardianship. FORMCHECKBOX Lost other coverage (attach proof of coverage) FORMCHECKBOX COBRA Coverage ended FORMCHECKBOX Marriage/domestic partnership FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Mailing Address – Street City State Zip FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Last NameFirst NameMISocial Security NumberDate of birthRelationshipEmployee’s DependentORPartner’s DependentOROther (Step-child or Legal Guardian) FORMCHECKBOX Son FORMCHECKBOX Daughter FORMCHECKBOX Son FORMCHECKBOX Daughter FORMCHECKBOX Male FORMCHECKBOX FemaleReason FORMCHECKBOX Birth/Adoption FORMCHECKBOX Court order/legal guardianship. FORMCHECKBOX Lost other coverage (attach proof of coverage) FORMCHECKBOX COBRA Coverage ended FORMCHECKBOX Marriage/domestic partnership FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Mailing Address – Street City State ZipDependent Eligibility Information: If you have listed a dependent child over the age of 18 years, please answer the questions below about your dependent:1. Incapacitated or Disabled? FORMCHECKBOX Yes FORMCHECKBOX No 2. Working full time and have access to health insurance? FORMCHECKBOX Yes FORMCHECKBOX NoIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the insurance company. Penalties include imprisonment, fines and denial of insurance benefits. Your dependents’ enrollment is subject to verifying their eligibility. Employee’s Signature ___________________________________________________ Date ____________________________________________Benefits Rep _______________________________________________________________ Date Entered into HRIS _________________________Revised 2/25/2020 ................
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