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County of Summit

Adult Dependent Eligibility Questionnaire (Ages 26-27) – Complete one per dependent

Section A – Completed by the County Employee

________________________________________ _____________________

Employee Name:

Department

YES

Do you have a dependent aged 26 or 27 you want covered on your County medical pla

If NO, complete Section B and return it to the Insurance Department.

Is the dependent that is age 26 or 27 employed?

YES

If NO, complete Section B and return it to the Insurance Department. If YES, complete this form in its entirety

and submit it to your dependent’s employer to be returned to the Insurance Department. If your dependent’s

employer faxes the completed form back to Insurance, it is your responsibility to make certain it is received by

the Insurance Dept. If your dependent is losing healthcare coverage, please have his/her employer complete the

back of this form.

Is this dependent covered under any other group medical insurance?

YES

If YES, identify the other insurance carrier: _______________________________________________________

Policy Number: _____________________________ Policyholder:_____________________________________

Is this dependent covered under Medicaid or Medicare?

YES

Section B – Employee Certification

I understand it is my responsibility to notify the County of Summit Insurance Department within 30 days in the

event that any change occurs in the employment/eligibility status of my adult dependent.

I understand that I am personally liable for any benefits paid should any of the information provided be

inaccurate.

I understand that any willful misrepresentation of facts on this enrollment form will be grounds for progressive

discipline and termination of benefits, and represents insurance fraud.

I certify that all the information provided in this form is correct to the best of my knowledge and authorize release

of any information requested with respect to the Certification.

I understand I am responsible for the monthly premium.

Employee Signature: ________________________________________

____________

______________

(Required)

Date

Last 4 digits of SSN

Section C – Adult Dependent Release

Dependent’s Name: __________________________________

Social Security Number: ____________________

(Please Print)

Relationship to County Employee: ___________________________ Date of Birth: __________________________

Address: _____________________________________________________________________________________

Number and Street

City

State

Zip

Student?

YES

NO Number of Credit Hours: _____ School Name: _________________________________

I authorize my employer to release to the County of Summit the information requested on this form.

Adult Dependent’s Signature: ___________________________________________ Date: __________________

We suggest your Adult Dependent request a copy of the completed form from his/her employer

and print his/her name in the subject line at the top of the form’s reverse side.

EMPLOYER: PLEASE FAX BOTH SIDES OF THE COMPLETED FORM TO:

The County of Summit – Insurance Department

FAX – 330-643-8625

If you have any questions, please call the Insurance Dept. at 330-643-2621

Over

Adult Dependent Eligibility Questionnaire (Ages 26-27) Form - The County Of Summit - Insurance Department

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