Csea Employee Benefit Fund Proof Of Student Status Form (Page 2 of 2) in pdf

Dear Member,

Our enrollment records indicate that you have a dependent child enrolled who is age 19 or over. Coverage for this dependent

may be continued up to his/her 25th birthday if a full-time student. Proof of student status is required annually. Coverage

terminates three months from the end of the month in which the student completes graduation requirements.

Please be advised that Dental and Vision benefits are not affected by the Federal Health

Care Reform Act. The EBF requires that proof of current student status be provided

annually in order to qualify for these benefits.

To qualify for continued coverage, the dependent must be a full-time student enrolled for at least 12 undergraduate or 6

graduate credit hours in an accredited college or university. The credits must be in a college degree program. The dependent

must be working towards a formal degree such as a Associates Arts Degree (AA, AS), Bachelor of Arts (BA), Bachelor of

Science (BS), Master of Arts (MA), Master of Science (MS), etc. Full-time high school students also qualify. Technical

courses for a short duration do not meet this requirement.

Please have the reverse side of this form completed by the registrar or obtain supporting documentation of full-time status,

such as a letter from the registrar, current semester schedule or transcript and attach it to this form. Pre-registration

statements, acceptance letters, and tuition bills cannot be accepted.

Note: The school may require a waiver to be signed by the student in order to release certain information. The Fund requires

a signed HIPAA waiver from all persons 18 and older in order for the Fund to release that person’s health information to a

third party.

This form is used only to update/validate the CSEA EBF dependent student eligibility file for Dental and/or Vision coverage.

Your Health Insurance carrier may require different or additional evidence of dependent student enrollment.

Thank you for your cooperation.

Member Services Department

CSEA Employee Benefit Fund

1-800-323-2732

Csea Employee Benefit Fund Proof Of Student Status Form Page 2