Fillable Medical, Dental And Vision Change Form printable pdf download

Medical, Dental and Vision

Change Form

Request for changes must be submitted within 30 days of a qualifying event.

Please print clearly.

Employee Information

Worksite Employer

Employee Last Name

First Name

9 Dig. Social Security Number

Contact information,

Home Phone

Cell Phone

if needed to process

form.

Drop All Coverage with a Qualifying Event

 Health

 Dental

 Vision

Drop date ___________________________________________. Due to:

 Employee no longer working 30 hours per week

 Employee and all dependents are eligible for other group coverage. *Letter of Creditable Coverage with start date required.

Drop Dependents

 From Health

 From Dental

 From Vision

Due to:

Effective Date:

Documentation Required:

Dependent Child’s Age

*Date of dependent’s 26

birthday: ________________

None



Separation

*Date no longer living together: ____________________

None

(Health Only)

Divorce

*Date divorce final: __________________________________

*Copy of Divorce Papers



(Dental & Vision)

Other Group Coverage

*Start date of New Coverage: ________________________

*Letter of Creditable Coverage with start date



Last Name

First Name

M.I.

Relation

Gender

Date of Birth

SSN

Last Name

First Name

M.I.

Relation

Gender

Date of Birth

SSN

Last Name

First Name

M.I.

Relation

Gender

Date of Birth

SSN

Last Name

First Name

M.I.

Relation

Gender

Date of Birth

SSN

* Required

Add Dependents

 To Health

 To Dental

 To Vision

Due to:

Effective Date:

Documentation Required:

Birth of Dependent

*Date of dependent’s birth: __________________________

*Copy of Birth Certificate



Marriage

*Date of marriage: ___________________________________

*Copy of Marriage Certificate



Adoption of Dependent

*Date placed in the home: __________________________

*Copy of Adoption Papers



Loss of Group Coverage

*Termination Date: __________________________________

*Letter of Creditable Coverage with end date

Last Name

First Name

M.I.

Relation

Gender

Date of Birth

SSN

Last Name

First Name

M.I.

Relation

Gender

Date of Birth

SSN

Last Name

First Name

M.I.

Relation

Gender

Date of Birth

SSN

Last Name

First Name

M.I.

Relation

Gender

Date of Birth

SSN

* Required

Change of Name or Address

Change Name To:

Change Mailing Address To:

Employee Signature and Certification of Information Accuracy

I understand the information presented to me about these plans, and I have made the coverage selections represented on this form. I authorize A Plus Benefits to make

deductions from my earnings for my share of the cost, if any, of the benefits to which I may become entitled. I also understand that coverage may only be dropped on

January 1

, or within 30 days of becoming eligible for another group plan of the same type. I certify that the information I have provided on this form is true and complete. I

understand that giving false or incomplete information may result in the retroactive loss of this coverage. I understand that I must work at least 30 hours per week to remain

eligible for these benefit plans. A photocopy of this form shall be as valid as the original. I understand that this form must be received by A Plus Benefits within 30 days of

the qualifying event in order to be processed.

________________________________________________________________________

____________________________________

MPLOYEE

IGNATURE

ATE

Office Use Only

Qualifying Event:

Effective Date:

Instructions:

Fax: 801-841-3534

A Plus Benefits