Required Supporting Documents to Add Dependent Coverage
All necessary documents as identied below must be submitted and veried before dependents can be covered under any
City of Houston benets plans. Some of the submitted documents must be County Clerk certied or court-led documents.
Each submitted document will be reviewed by the Benets Division for approval before processing changes to coverage.
Legal Spouse Biological Children
(under age 26)
Stepchildren
(under age 26)
Biological
Grandchildren*
(under age 25)
Adopted/Court
Ordered Dependents
Social Security Card
Marriage Certicate (front)
Marriage Certicate (back)
OR
Social Security Card
Declaration of Registration
of Informal Marriage
(Common Law)
Social Security Card
Birth Certicate
OR
Social Security Card
Verication of Birth Facts
Social Security Card
Birth Certicate
Marriage Certicate (front)
Marriage Certicate (back)
Social Security Card
Birth Certicate
Current IRS Filing
Birth Certicate of
Grandchild
Birth Certicate of
Grandchild’s Natural Parent/
Employee’s Biological Child
*step-grandchildren are
not eligible for coverage
Social Security Card
Adoption/Guardianship
Documents
Birth Certicate
OR
Social Security Card
Custody/Court Order
Documents
Birth Certicate
Note: Eligible Dependent - An eligible dependent is your legal spouse and any child (natural, adopted, foster, grandchild, stepchild, and a child for whom you are
legal guardian and/or have legal support obligation) who is your dependent for federal income tax purposes, resides with you, and is under age 26 or under age 25 for
grandchild(ren).
Disabled children age 26 and over - Child must be primarily supported by you, and incapable of self-sustaining employment by reason of mental incapacity, physical
disability or handicap, which arose while the child was covered as a dependent on a city plan without a break in coverage. Upon applying and receiving third party medical
administrator’s approval, proof of the child’s condition and dependence must be submitted within 31 days or the child ceases to qualify for benets.
Important - If both you and your spouse work(ed) for the city, you may be covered as an employee/retiree or as a dependent - but not both. Dependents may be enrolled
under only one parent or guardian.
Supporting Documents Required to Change Coverage as a Result of a Qualifying Event
Newborn Marriage Divorce Lost or Obtained Medical Coverage
Verication of Birth Facts (within 31
days)
Social Security Card (within 60 days)
Marriage Certicate (front)
Marriage Certicate (back)
Social Security Card
Copy of Divorce Decree
Letter of Creditable Coverage
Drop Child/Grandchild/
Stepchild Over 18
Drop Ineligible Dependent Return from Military
Service
No support needed
No support needed
No support needed
I hereby certify that the dependent(s) listed above is/are my dependent(s) as dened by the Internal Revenue Service and as dened in the City of Houston Health
Benets plans. I further certify that the information and all supporting documentation submitted with this application or in the future in connection herewith is true
and correct. Any misrepresentation (overt or by omission) may be considered a fraudulent act. Therefore, any fraudulent act or refusal to provide the documentation
required shall be grounds for denial of coverage or refusal or rescission of coverage applicable to the dependent(s) for whom the misrepresentation relates. Neither, the
insurance carrier, the City of Houston or the plan administrator will have further liability or obligation to cover the expenses of such dependent(s). The City of Houston or
carrier would also be entitled to recover any expenses incurred and improperly paid by it by reason of such misrepresentation. This certication is made under penalty
of perjury for the consideration and purpose of obtaining benets for said dependent(s) designated on this form.
Employee Authorization of Payroll Deductions
I am an employee of the City of Houston, eligible to participate in the medical and dental and vision program. I apply to participate and understand that the information
I have provided above is part of my application. All statements made by me may be relied upon by the city. If any information that I have provided is found to be mate-
rially incorrect, my coverage may be denied. I realize that any medical coverage I or my dependents are eligible for at this time, which I decline, may be available in the
future if I provide proof of a change in family status within 31 days of family status change.
I agree that if I have listed ineligible dependents, my medical coverage may be cancelled. I authorize the City of Houston to deduct from my wages or salary my portion
of the contribution as it becomes due. I understand that I must notify the City of Houston when I have an ineligible dependent, and that I may receive a refund of premi-
ums paid for an ineligible dependent for up to two months. I will be responsible for any and all medical, dental and vision claims paid on an ineligible dependent.
Print Employee Name: Employee Signature:
Date: Employee ID#:
For Internal Use Only
Received by: Processed by: QC Review by:
Date: Date: Date:
Revised 5/2020
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