HEALTH CARE COVERAGE CHANGE FORM

HEALTH CARE COVERAGE CHANGE FORM
Employee Name
Empl ID#
Address
City
State
Email Address
Work Phone
Zip Code
Home/Cell Phone
If You Experienced an Event that will Allow You to Enroll in the Health Plan and You are Not Already Enrolled,
Please Use the Health Care and Dental Coverage Enrollment Form
Please Indicate Type Of Change:
Please Indicate Date Of Status Change Event: ____________________________________
† Addition of family member(s)
†
†
†
†
†
†
†
†
† Deletion of family member(s)
† Drop coverage for all – employee
and dependent(s)
† Student certification (you must
complete the back of this form)
† Request COBRA coverage
Dependent
Type
Spouse
Dependent
Children
(Includes:
Adopted
Children,
Step
Children, and
Legal
Guardianship
Children)
Check
Option
Marriage
Divorce
Death
Birth
Adoption
Foster Care/Legal Guardianship
Loss of Other Coverage
Obtained Other Coverage
Name
(Include Last Name if Different from
Employee)
Relationship
[ ] Add
[ ] Delete
[ ] Husband
[ ] Add
[ ] Delete
[ ] Daughter
[ ] Add
[ ] Delete
[ ] Daughter
[ ] Add
[ ] Delete
[ ] Daughter
[ ] Add
[ ] Delete
[ ] Daughter
[ ] Add
[ ] Delete
[ ] Daughter
Dependent no longer eligible:
† Marriage
† No Longer Dependent on Employee for 50% of Support
† Age 26
† No Longer Full-Time Student
† No Longer Qualifies for Handicap Extension
Social Security
Number
Birth Date
Address if Different from Employee
[ ] Wife
[ ] Son
[ ] Son
[ ] Son
[ ] Son
[ ] Son
Please return this completed form to:
University of Utah Benefits Department ~ 420 Wakara Way, Suite 105, Salt Lake City, UT 84108
Phone: (801) 581-7447 Fax: (801) 585-7375
I hereby request that the University of Utah Health Care Plan, hereinafter known as the Plan, change my membership in
the Plan as noted hereon, subject to prevailing rules and regulations of the Plan. I certify that any information provided
on this form is true and correct. I understand any family status change to my coverage must be made within three
months of the event and may affect my monthly contribution rate. I understand that new coverage will be effective
retroactive to the event date, unless I request that it be effective the day of this request. If this change results in an
increase in my contribution rate, I acknowledge that any contributions due will be retroactively deducted from my pay.
Failure to make the change within 3 months of the event will require that I wait until the next annual open enrollment to
make the change. I understand that I must notify the Benefits Department within 60 days of the date my dependent
becomes ineligible for coverage in order for the dependent to be eligible for COBRA Continuation Coverage.
Any person who knowingly files an enrollment form containing any misrepresentation or any false,
incomplete, or misleading information may be subject to discipline up to and including termination of
employment and cancellation of coverage, and may be guilty of a criminal act punishable under law and
subject to civil penalties.
Date:
Employee Signature:
Coverage change from:
Coverage change to:
FOR BENEFITS DEPARTMENT USE ONLY
Effective date:
Date eligible for COBRA:
Date sent to COBRA:
6.08
STATEMENT OF UNDERSTANDING AND AGREEMENT
FOR STUDENT-DEPENDENT CERTIFICATION
Student-dependents listed on the reverse side of this form must meet ALL of the requirements listed below and provide
a certified copy of student status from the institution your dependent is attending:
1.
The student must continuously remain unmarried and the employee must continue providing at least
50% of the student’s support.
2.
The student must be enrolled on a full-time basis in an accredited university, college or vocational
school; provided, however, that eligibility for coverage will continue during one semester if the student
is enrolled full-time in the prior semester and will be enrolled in the next semester. This information
must be verified upon the dependent’s 26th birthday. Recertification will be requested annually by the
claims administrator.
The student will cease to be eligible for coverage and benefits on his/her graduation date, the last day the student
attends classes, or if a change of status occurs wherein the student fails to meet any of the above conditions. Under
such circumstances, the student may be eligible for continuation of coverage through COBRA if the Benefits Department
is notified of the change in status within 60 days. Contact the University Benefits Department at (801) 581-7447 for
details.
STUDENT’S FULL NAME:
BIRTH DATE:
NAME OF SCHOOL
STUDENT IS ATTENDING:
ANTICIPATED GRADUATION
DATE:
[ ] INCLUDE INSTITUTION CERTIFICATION
SCHOOL ADDRESS:
CITY:
EMPLOYEE SIGNATURE _____________________________________________________________
STATE:
ZIP:
DATE ______________________________
(USE IF MORE THAN ONE DEPENDENT IS BEING CERTIFIED)
STUDENT’S FULL NAME:
BIRTH DATE:
NAME OF SCHOOL
STUDENT IS ATTENDING:
ANTICIPATED GRADUATION
DATE:
[ ] INCLUDE INSTITUTION CERTIFICATION
SCHOOL ADDRESS:
CITY:
EMPLOYEE SIGNATURE _____________________________________________________________
STATE:
ZIP:
DATE ______________________________
6.08