Dependent Eligibility Verification Form

Dependent Eligibility Verification Form
Employee Name:_______________________________________
Employee #: _____________
I wish to add or drop the listed dependents from the following plans:
Medical, Dental and Vision*
Vision Only*
Dental Only
Medical Only
*Temporary Employees are not eligible for vision coverage
Event Type
Date of
Event
Deadline to Enroll/Remove Dependents From Coverage
Benefits Effective/End Date
ADD DEPENDENT/S:
1st day of the following calendar month OR if hired
on the 1st working day of the month coverage will
be effective on the date of hire. Temporary
employees are effective the 1st day of the month
following 60 days of continuous employment.
1st day of the following calendar month
New Hire
Within 31 days of Benefits effective date
Marriage
Domestic Partner
Within 31 days of marriage
Within 31 days of establishing Domestic Partnership
Birth
Within 60 days of birth
Date of birth
Adoption
Within 60 days of adoption or placement for adoption
Legal Custody
Loss of coverage
Within 60 days of court-appointed legal guardianship
Within 31 days of loss of coverage OR 60 days for
involuntary loss of coverage under Medicaid or the
Children’s Health Insurance Program (CHIP)
Last day of Open Enrollment
Date of birth for a child adopted or placed for
adoption within 60 days of birth
Date of adoption or placement for a child older
than 60 days of birth
1st day of the following calendar month
1st day of the following calendar month
11/2015
Annual Open
Enrollment
Other (Explain)
DROP DEPENDENT/S:
1st day of the following calendar month
The 1st of January the next calendar year
Obtained other
Coverage
Divorce/Legal
Separation
Dissolution of
Domestic Partnership
Within 31 days of obtaining other coverage
The last day of the prior calendar month
Within 31 days of the divorce or legal separation
The last day of the calendar month
Within 31 days of the dissolution of the domestic partnership
The last day of the calendar month
Death of a Dependent
Within 31 days of the death
Date of death
Other (Explain)
List all eligible dependents to be added to or removed from your benefit plan(s) AND attach required supporting
documentation as identified on the reverse of this form by the required deadline date listed above.
Dependent Name
Relationship
Birthdate
Tax
Dependent
Yes
No
City of Tacoma
Employee?
Yes
No
Spouse
DP
Child
DP Child
Step Child
SSN:
Spouse
SSN:
DP
Child
DP Child
Step Child
Yes
No
Yes
No
Spouse
SSN:
DP
Child
DP Child
Step Child
Yes
No
Yes
No
Spouse
SSN:
DP
Child
DP Child
Step Child
Yes
No
Yes
No
Spouse
DP
Child
DP Child
Step Child
Yes
No
Yes
No
SSN:
Spouse
SSN:
DP
Child
DP Child
Step Child
Yes
No
Yes
No
Sex
M or F
By signing below, I understand that if I am found to be covering an ineligible dependent(s), it may be considered fraud or intentional misrepresentation and
could result in discipline up to and including termination of employment and the termination of coverage, including retroactive termination of coverage for my
ineligible dependent(s), and I may be responsible for repayment of claims and any costs associated with providing coverage to the ineligible dependent(s).
Employee Signature _______________________________________________ Date ____________________
Benefits Office Use Only
Daytime Phone Number_____________________________________________
Eligibility verified by: _____________
Revised 9/2015
*Definitions and Accepted Supporting Documentation for Dependent Eligibility*
ADDING DEPENDENTS
Review the below information to ensure the dependents you wish to add to your City of Tacoma benefits meet the plan
eligibility requirements and to determine what supporting documentation must be submitted by the deadline dates listed
on the reverse side of this form. Supporting documentation will vary based on the reason your dependent is being added.
REMOVING DEPENDENTS
Review the below information for the supporting documentation that must be submitted by the deadline dates listed on
the reverse side of this form. Supporting documentation will vary based on the reason your dependent is being dropped.
Spouse: Your current legal spouse
Add to coverage:

A current valid legal marriage certificate, which must include the date of marriage that supports the current spousal relationship.

Verification documents that the spouse has lost other insurance coverage.
Drop from coverage:

A copy of the divorce decree (first and last page) or copy of the court ordered legal separation paperwork (first and last page).

Verification documents that the spouse has obtained other insurance coverage.
Domestic Partner: Your current Domestic Partner who meets the requirements on the City of Tacoma Affidavit of Domestic Partnership
OR is recognized by the State of Washington under chapter 26.60 RCW
Add to coverage:

A City of Tacoma “Affidavit of Domestic Partnership” form AND one of the following documents:
A utility bill, joint bank account statement or vehicle registration listing the names of you and your domestic partner and dated
within the last 90 days.
A lease/mortgage or insurance statement listing the names of both you and your domestic partner or copy of your domestic
partner’s valid driver’s license/state ID showing the address to be the same as your address on file.

Record of declaration of State Registered Domestic Partnership.

Verification documents that the domestic partner has lost other insurance coverage.
Drop from coverage:

A City of Tacoma “Affidavit of Termination of Domestic Partnership” form.

Record of dissolution of State Registered Domestic Partnership.

Verification documents that the domestic partner has obtained other insurance coverage.
Child under age 26: Your children to age 26 may include: A natural child, adopted child or a child legally placed with you for adoption
including a child for whom you have assumed a total or partial legal obligation for support in anticipation of adoption, a stepchild or
domestic partner’s child or a child for whom you have legal guardianship or court-ordered custody.
*Note: If you are providing documentation for a child of your legal spouse or domestic partner, you must also submit eligibility
documentation for your Spouse or Domestic Partner, unless this information has been previously submitted.
Add to coverage:

The child’s legal birth certificate naming you, your spouse or your domestic partner as the child’s parent.

A final court order (divorce decree/custody agreement) naming you, your spouse or your domestic partner as the child’s parent.

Legal adoption papers issued by the courts naming you, your spouse or your domestic partner as the adoptive parent.

Legal guardianship/custodian papers issued by the courts naming you, your spouse or your domestic partner as the child’s
guardian/custodian.

A Qualified Medical Child Support Order (QMCSO) showing you are required to provide medical coverage for the child.

Verification documents that the child has lost other insurance coverage.
Drop from coverage:

Verification documents that the child has obtained other insurance coverage.

A final court ordered (divorce decree/legal separation) between you and your spouse.

A City of Tacoma “Affidavit of Termination of Domestic Partnership” form.
Child age 26 and over: Any dependent disabled child, over the age of 26 who otherwise meets the criteria for “child” and is incapacitated
due to developmental disability, physical handicap, or a mental health diagnosis, that would prevent the child from establishing and
maintaining consistent employment or independence, provided the child was covered on the day before the 26th birthday and the
incapacity occurred prior to the 26th birthday.
Please contact the Benefits Office at 253-573-2345 or [email protected] for further information.
The IRS has established rules for your elections, which dictate that once you have made your elections for the plan year, you must not
change them until the next annual Open Enrollment period, unless a qualifying life event occurs. When experiencing a Qualifying Life
Event, refer to the Qualifying Life Event document on the Benefits Division website for more details about other changes you may want to
consider with your benefit elections, beneficiary designations, tax withholding, etc.
City of Tacoma Benefits Office | 253-573-2345 | [email protected] | 747 Market St., Rm. 1420, Tacoma, WA 98402
Revised 9/2015