Fillable City of Boulder Life Event Benefits Change Form (City of Boulder)

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City of Boulder Life Event Benefits Change Form (City of Boulder)

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City of Boulder Life Event Benefits Change Form
Please return completed/signed form to HR
HRBenefitsForms@bouldercolorado.gov
3065 Center Green Drive
Boulder, CO 80301
Revised 11-05-2019 1
Eff. Date: _____________
HR Use Only
SMBO _____ Munis _____
EMPLOYEE INFORMATION
Printed Name:
____________________________________________________________________________________________________________
(First) (Middle Initial) (Last)
Emp ID#: _____________
LIFE EVENT ACTIONS
The City of Boulder plans allow for changes outside of annual open enrollment only when an event creates a special open enrollment period. The change
must be allowable under the Internal Revenue Code and correspond to and be consistent with the special life event. (Speak with Human Resources to know
what corresponds to your event.) You are required to provide proof of the event that creates the special period allowing changes. You must submit this
form and proof of the event no later than 31 days after the event. More details on life mid-year plan changes can be found in the benefits guide.
Provide Date of Event: __________________________________________________
Attach relationship and/or event
documentation
ENROLL/CHANGE due to event:
CANCEL due to event:
Comments:
Birth/Adoption
Marriage
Domestic Partnership/Civil Union
Court Order
Involuntary Loss of Coverage
Return from Leave
Change in Employment Status
Change in Dependent Care Cost
Other (explain in comments box)
Unpaid Leave of Absence
Divorce/Legal Separation
Termination of Partnership/Union
Death of a Dependent
Child over age 26
Family Member
Other (explain in comments box)
Name Change *Bring your new social security card to Human Resources front desk for confirmation and copying
Current Name: _____________________________________________________________________________________________________________
(First) (Middle Initial) (Last)
New Name: * _____________________________________________________________________________________________________________
(First) (Middle Initial) (Last)
CHOOSE PLAN TO ADD OR REMOVE THE FOLLOWING DEPENDENTS TO/FROM MY COVERAGE
CIGNA HEALTHCARE
DELTA DENTAL
Plan:
$1,000 Deductible Open Access Plan
$1,500 Deductible and HSA-Eligible Open
$5,000 Deductible and HSA-Eligible Open
Waive Medical Coverage
Delta Premier (High Plan)
Delta Preferred (Low Plan)
Waive Dental Coverage
Enroll-Buy Up
Waive Vision Coverage
Tier:
Employee Only
Employee + 1 Dependent
Employee + Family
Employee Only
Employee + 1 Dependent
Employee + Family
Employee + 1 Dependent
Employee + Family
City of Boulder Life Event Benefits Change Form
Please return completed/signed form to HR
HRBenefitsForms@bouldercolorado.gov
3065 Center Green Drive
Boulder, CO 80301
Revised 11-05-2019 2
Use A to Add and R to Remove the following Dependents to/from my coverage:
Note: Allowable relationships include spouse, domestic partner, civil union partner, birth child, adopted child, child for whom you have legal
guardianship, disabled child over the age of 26, partner’s child for whom you are responsible (dependent per the IRS guidelines), step child, any other
person you have been granted legal guardianship for through the courts. Proof of eligibility may be required.
Health Care Flexible Spending Account (HC FSA)
Available to all benefits eligible employees who are not participating in an HSA account. Eligible expenses must be incurred between January 1 and
March 15 of the following year. Any monies remaining in the account as of March 31 are forfeited. Enrolling requires a supplemental form.
Enroll/Change
Waive
What amount would you like to contribute to
this account via payroll deduction for the
remainder of the year?
Annual Election Amount
$________________________________
(minimum $120, maximum $2,750)
Dependent Care Flexible Spending Account (DC FSA) (Day Care)
Available to all benefits eligible employees. Eligible expenses must be incurred between January 1 and March 15 of the following year. Any monies
remaining in the account as of March 31 are forfeited. Enroll, requires a supplemental form.
Enroll/Change
Waive
If you are choosing to enroll, what amount
would you like to contribute to this account via
payroll deduction for the remainder of the
year?
Annual Election Amount
$________________________________
(minimum $120, maximum $5,000)
Health Savings Account (HSA) Enrollment
Available to all employees who elect the $1,500 or $5,000 Deductible plan. Eligible expenses must be incurred after the creation of the account. Any
monies remaining in the account at the end of the year are retained by the employee. Employees age 55 or older may contribute an additional $1,000.
*If you are going from Family to Single or Single to Family please contact your financial institution for IRS limits.* Please also complete the HSA
Enrollment Form.
Enroll 55+ Catch up
Waive
If you are choosing to enroll, what amount
would you like to contribute to this account via
payroll deduction each pay period?
Per Pay Period Election Amount
$________________________________
HSA Changes:
HSA Changes:
A/R
Dependent’s Name
(First, MI, Last)
Relationship*
Dependent’s
Social Security #
Required
Male
Or
Female
Date of Birth
(MM/DD/YYYY)
Required
Disabled
(Y/N)
Add to
Medical
(Y/N)
Add to
Dental
(Y/N)
Add to
Vision
(Y/N)
City of Boulder Life Event Benefits Change Form
Please return completed/signed form to HR
HRBenefitsForms@bouldercolorado.gov
3065 Center Green Drive
Boulder, CO 80301
Revised 11-05-2019 3
Cancel contributions
Increase or Decrease contributions
New dollar amount per pay check:
$_________________
Apply the change for:
The remainder of the payroll year
A set number of pay checks: _____________
Supplemental Retirement Savings
457 plan administered by ICMA
401(k) plan administered by PERA
Enroll, requires a supplemental form
Cancel contributions
Increase or Decrease contributions
50+ Catch up
New Pre-tax: ___________% or $____________
New Post-tax (ROTH): _ n/a % - $____________
Enroll, requires a supplemental form
Cancel Contributions
Increase or Decrease contributions
50+ Catch up
New Pre-tax: ___________% or $____________
New Post-tax (ROTH): _ n/a % - $____________
Alfac
Enroll, requires a supplemental form
Waive
LegalShield Plan IDShield
Enroll, requires a supplemental form
Waive
Enroll, requires a supplemental form
Waive
Pets Best – Begin enrollment at petsbest.com/COBPETS – Discount code COBPETS
Signature for Insurance Carriers
I confirm that the information I have provided on this form is complete and accurate.
I understand that the benefit plans that I have selected provide reimbursement for certain costs, which are more fully described in the current
Certificate of Coverage or Summary Plan Description. I understand there may be instances where treatment decisions made by my physician or
me or expenses which I have incurred may not be covered by my benefit plan.
I understand that the terms of the contract between the insurance carrier and my employer may not allow late enrollment for me and my
dependents.
I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention products or
services that might be valuable to me and otherwise as permitted by law. I understand that my information on benefits may be combined in
aggregate at the carrier level with other member’s information so that it is no longer individually identifiable and can be used for commercial and
other purposes.
I authorize payroll deduction of any applicable employee premiums for these benefits.
Signature: ____________________________________________________________ Date: _______________________________
Employees working in standard positions but working less than 20 hours per week are not eligible to participate in any of the above insurance plans.
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City of Boulder Life Event Benefits Change Form (City of Boulder)

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Completed 7 April 2021

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