Coverage can be added within one month (31 days max) of: 1) initial eligibility as a new hire, 2) a change in status to
benefits-eligible, 3) a qualifying life event; or 4) during an announced open enrollment period, enrollment is effective
Jan. 1 of the following year. Enrollment is not retroactive (exception for newborns). IMPORTANT: unless acceptable documentation is received, the dependent will not be enrolled. That means if you are adding coverage, you will be enrolled but not your dependent(s).
All supporting documentation as described below must be submitted at the time of enrollment. Benefit enrollment
forms to enroll dependents will not be accepted if documentation is not provided. Therefore, you may be required to recomplete forms for “employee only” coverage initially, with the option to revise your enrollment within 31 days.
This certifies that all dependents covered under my health, dental or vision insurance are my legal dependents as defined below. I understand that insurance fraud is generally defined as the “intentional misrepresentation of material facts and circumstances to an insurance company to obtain payment that would not otherwise be made” and disciplinary action will be taken, up to and including termination, should this occur. In addition, I understand I will be held liable for any claims or fees incurred for the individual that is not a dependent.