FLEX BENEFITS QUALIFYING LIFE EVENT CHANGE FORM 2016

Benefits Change Form
(Qualifying Life Event/Family Status)
FLEX BENEFITS QUALIFYING LIFE EVENT CHANGE FORM
2016 HEALTH AND DENTAL PLAN
SWORN LAPD & LAFD
When you experience a qualifying life event, you have 30 days from the date of the event to notify and make changes to your benefits
by contacting Maria Lopez at 213-978-1584. You will have 60 days from the date of contact to submit documentation to the Employee
Benefits Division. This includes, but is not limited to documents such as birth certificates, marriage certificates, divorce decrees, court
orders, full-time student certificates, Cash-in-Lieu Affidavits, Domestic Partnership Affidavits, etc. Failure to submit documentation
within 60 days will cancel your changes on day 61. New dependents will not be offered COBRA. You will be responsible for any
rejected claims that are incurred as a result of the cancellation, regardless of when you are notified of the cancellation.
SECTION A
EMPLOYEE/SUBSCRIBER INFORMATION
EMPLOYEE ID OR SSN
LAST NAME, FIRST NAME, MIDDLE INITIAL
ADDRESS, CITY, STATE, ZIP
SEX (M/F)
PHONE NUMBER
EMAIL ADDRESS
SECTION B
WHAT QUALIFYING LIFE EVENT DID YOU/YOUR DEPENDENT EXPERIENCE?
Marriage
Divorce
Birth/Adoption
Begin Domestic Partnership
Death
Moved Outside of Service Area
Gain of Coverage
End Domestic Partnership
Loss of Coverage
Child no longer eligible
Court Order
Significant change in spouse/domestic partner’s employer coverage
SECTION C
DEPENDENT INFORMATION (ADD OR DELETE COVERAGE)
NAME
S
E
X
SSN
RELATIONSHIP
BIRTH
DATE
COVERAGE
ADD
DELETE
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
Medical
Dental
PRIMARY
CARE
PHYSICIAN ID1
PRIMARY
CARE
DENTIST ID2
1) Fill out the Primary Care Physician ID only if you selected the Blue Shield Access† HMO SaveNet (Narrow Network) plan. To
find the ID of your doctor/medical group, please visit blueshieldca.com/lacity and use the “Find a Provider” option.
2) Fill out the Primary Care Dentist ID only if you selected the DeltaCare USA DHMO plan. To find the ID of your dentist, please
visit deltadentalins.com/ and use the “Find a Dentist” option.
SECTION D – As a result of my qualifying life event . . .
. . . I would like to SWITCH coverage and join the
following medical/dental plans
. . . I would like to CANCEL my enrollment in the
following medical/dental plans
Kaiser Permanente HMO (17)
Kaiser Permanente HMO (17)
Blue Shield Access† HMO SaveNet (Narrow Network) (16)
Blue Shield Access† HMO SaveNet (Narrow Network) (16)
Shield Spectrum PPO (13)
Shield Spectrum PPO (13)
DeltaCare USA DHMO (19)
DeltaCare USA DHMO (19)
Delta Dental PPO (18)
Delta Dental PPO (18)
Cash-in-Lieu (CL) can also be elected using the online site
Cash-in-Lieu (CL)
No change – I do not wish to change plans
I do not wish to cancel my current coverage
SECTION E – If ending coverage for a family member, please fill out Section E.
For the purpose of notifying any removed dependents of their COBRA rights, please provide their mailing address.
Mailing address:
All required documentation, including this form, must be submitted to:
City of Los Angeles, Personnel Department
Employee Benefits Division
200 North Spring Street, City Hall #867
Los Angeles, CA 90012
You may also fax the documents to 213-978-1623 or
email them to [email protected]
E-mail is preferred so that you can receive an
acknowledgement of receipt.
Contact Maria Lopez at 213-978-1584 if you have questions.
BINDING ARBITRATION
I understand this election will remain in effect so long as I remain eligible or until I make another election during a valid
enrollment period or qualifying life event. I hereby authorize 1) the City of Los Angeles’ Office of the Controller to deduct my
share of monthly premiums from my salary as a result of this election; and 2) my medical and/or dental insurance provider to pay
claim under the plan selected. By signing this form, I indicate my interest in enrolling myself and any listed dependents into the
City’s Flex Benefits Plan and I understand that it is my responsibility to report any change in the eligibility of my dependents. I
also understand that I must abide by the provisions of the plan in which I enroll, and that any controversy between any HMO plan
member and such HMO (including its agents, staff physicians, employees, and providers) is subject to binding arbitration.
SECTION F
_________________________________________________________________________
EMPLOYEE SIGNATURE
DATE
OFFICE USE ONLY
EFFECTIVE DATE_________________________
MOU___________________
HEALTH SUB/PART_______________________
DENTAL SUB/PART___________________
PAY PERIOD ENDING ____________________________
10/2015