Download Mid-Year Qualified Life Event (QLE) Form To add

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Employee: If you have a mid-year Qualifying Life Event (QLE) that affects ANY of your City health insurance benefits, it is your responsibility to complete this
form and send to the Human Resources within 31 days of the qualifying event date in order to make the mid-year change. However, if you miss the 31 day timeframe, you will be
st
able to enroll that dependent during the next annual open enrollment period with an effective date of the 1 of the year of coverage. If you are making contribution $ changes to a
flex account due to the QLE, please also fill out the Flex Change of Status form. Documentation is required regarding the QLE, as previously described.
If you have any questions, please call HR/Benefits Coordinator: Ph: 657-8265 or Email: [email protected]
◊ Please PRINT & complete all sections ◊
Employee Name: ______________________________________________Qualifying Life Event (QLE) is:
__________________________________________
QLE Date (effective date of change): _________________________ To add qualifying dependent(s) below, I provided:
Marriage or Declaration legal certificate
Birth Certificate
*To add a new baby, you will probably not have the SSN within the 31 days. Please go ahead and submit this form & birth certificate and then call/email when SSN received
Dependents full Name,
including, middle initial
SS number*
Date of
Birth
Medical
Plan
Dental
Plan
Spouse
ADD
ADD
ADD
ADD
ADD
Male Child
DELETE
DELETE
DELETE
DELETE
DELETE
Female Child
Spouse
ADD
ADD
ADD
ADD
ADD
Male Child
DELETE
DELETE
DELETE
DELETE
DELETE
Female Child
Spouse
ADD
ADD
ADD
ADD
ADD
Male Child
DELETE
DELETE
DELETE
DELETE
DELETE
Female Child
Spouse
ADD
ADD
ADD
ADD
ADD
Male Child
DELETE
DELETE
DELETE
DELETE
DELETE
Relationship to
employee
Dependent Care
(Daycare)Flex
Medical
Flex/Health FSA
Vendor: EBMS
Vision Plan
Vendor: VSP
Female Child
By signing below, I understand that if I have a change in premium based on the QLE date; Payroll will catchup premiums at the next available payday for payrolls
missed. Also if I was receiving the Employee only, HDHP premium kickback benefit, the City will need to process a “miscellaneous health insurance” deduction to
take those monies back, however the actual funds you received will stay in your HSA or Medical Flex account.
Employee Signature: ____________________________________________________ Date: ____________________________
Phone #:______________________________ Email: ______________________________________
HR ONLY - PAYROLL Instructions:
Rev. 06/01/2016
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