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CalHR 781 Page 1 of 5 (rev 5/2020)
Dependent Eligibility Verification Checklist
California Department of Human Resources
State of California
Completion of this form is required when adding dependents to health, dental, or premier vision
benefits, and recertifying dependents for continued enrollment.
By completing this form, employees are certifying that the information submitted is true and
accurate and departmental human resources (HR) representatives are certifying that they have
received and reviewed supporting documents to verify an employee's dependent eligibility.
Employee:
Department:
Dependent Name
Dependent Type
Section I
Required Forms and Acceptable Documents to Determine Dependent Eligibility
Spouse/Registered Domestic Partner
Required Enrollment Forms
1
Acceptable Document(s) to Verify Eligibility for Initial Enrollment
and Health and Dental Benefit Triennial Re-verification
Health:
Health Benefit Plan
Enrollment Form
(HBD-12)
Dental:
Dental Plan Enrollment
Authorization (STD. 692)
Premier Vision:
Premier Vision Plan
Enrollment Authorization
(CalHR 774)
Copy
of the official government issued Marriage Certificate or
Declaration of Domestic Partnership*
AND**
Copy of the first page of the employee's income tax return from
the previous tax year listing the employee and the spouse or
domestic partner,
OR
Copies of a combination of other documents, including but not
limited to, a household bill, account statement, or insurance policy
listing the name and address of the employee and the spouse or
domestic partner, or other documents substantiating a current
marriage or domestic partnership.
Other documents that are older than 60 calendar days are
unacceptable.
*Departmental HR offices may waive the government issued Marriage Certificate or
Declaration of Domestic Partnership in the employee's second and subsequent
triennial re-verifications if the document is in the employee's Official Personnel File
(OPF).
**In the initial enrollment, the additional documents are not required if the marriage or
domestic partnership occurred within the last six months.
1
Unless otherwise requested by the HR office, these enrollment forms are only required when adding or deleting
dependents from a plan.
CalHR 781 Page 2 of 5 (rev 5/2020)
Required Enrollment Forms
1
Acceptable Document(s) to Verify Eligibility for Initial Enrollment
and Health and Dental Benefit Triennial Re-verification
Health:
Health Benefit Plan
Enrollment Form
(HBD-12)
Dental:
Dental Plan Enrollment
Authorization (STD. 692)
Premier Vision:
Premier Vision Plan
Enrollment Authorization
(CalHR 774)
1
Unless otherwise requested by the
HR office, these enrollment forms
are only required when adding or
deleting dependents from a plan.
A copy of the following documents that name the employee, spouse, or
domestic partner as the child's parent or guardian:
Birth Certificate** (Birth certificate for newborns is due at the time of
enrollment or 60 days after the effective date. Until the birth certificate
is available, the employee must provide an official hospital birth record
of the child.)
Adoption Certificate**
Court Order
**Departmental HR offices may waive in employee's second and subsequent triennial
re-verifications if the certificate is in the employee's OPF, and current marriage or
domestic partnership to the parent of the step or domestic partner
child(ren) is re-verified.
Required Enrollment Forms
1
Required Documents to Certify Initial Enrollment Eligibility
and to Recertify Continued Enrollment Eligibility
Health:
Health Benefit Plan
Enrollment Form
(HBD-12)
Dental:
Dental Plan Enrollment
Authorization (STD. 692)
Premier Vision:
Premier Vision Plan
Enrollment Authorization
(CalHR 774)
1
Unless otherwise requested by the
HR office, these enrollment forms
are only required when adding or
deleting dependents from a plan.
Member Questionnaire for Disabled Dependent (HBD-98)
AND
Medical Report for Disabled Dependent (HBD-34)
*The initial certification must occur within 60 days before and ending 60 days after the
child’s 26
th
birthday (employee and child currently enrolled), or within 60 days of a
newly eligible employee’s initial health enrollment.
CalHR 781 Page 3 of 5 (rev 5/2020)
Dependent in Parent-Child Relationship (PCR)
Required Enrollment Forms
Acceptable Document(s) to Verify Eligibility
Health:
Health Benefit Plan
Enrollment Form
(HBD-12)
Affidavit of Parent-Child
Relationship (HBD-40)
Dental:
Dental Plan Enrollment
Authorization (STD. 692)
Affidavit of Parent-Child
Relationship (CalHR 025)
Premier Vision:
Premier Vision Plan
Enrollment Authorization
(CalHR 774)
To
ENROLL
PCR dependent(s) under age 19
Copy of first page of employee's income tax return from previous
tax year listing child as a tax dependent,
OR
Copies of other documents substantiating the child's financial
dependence on employee, including, but not limited to: current legal
judgments/court documents showing the employee's legal parental
status or duties/guardianship over the child; bank, credit card, tuition
or insurance statements/payments; school records; bills or mail
indicating common residency with the dependent.
These other documents are only acceptable in lieu of a tax return
for a time not to exceed one tax filing year for PCR dependents
under age 19.
To
ENROLL
PCR dependent(s) age 19 to 26
Copy of first page of employee's income tax return from previous
tax year listing child as a tax dependent,
OR
Copies of other documents, as listed above, substantiating the
child's financial dependence on employee, provided that the child:
Lives with employee for more than 50 percent of time, or is a full-
time
student, AND
Is dependent on employee for more than 50 percent of the
child's support.
Annual Recertification of PCR Dependent
Follow recertification instructions in CalPERS Circular Letter #600-008-15
Required Recertification
Forms
Acceptable Document(s) to Recertify Eligibility
To recertify continued
enrollment for health, dental,
and premier vision (if
applicable) benefits:
Affidavit of Parent-Child
Relationship (HBD-40)
To recertify continued
enrollment for dental and
premier vision (if
applicable) benefits:
Affidavit of Parent-Child
Relationship (CalHR 025)
To RECERTIFY PCR dependent(s) under age 19
Copy of first page of employee's income tax return from previous tax
year listing child as a tax dependent
To
RECERTIFY
PCR dependent(s) age 19 to 26
Copy of first page of employee's income tax return from previous tax
year listing child as a tax dependent,
OR
Copies of other documents, as listed for initial PCR dependent
enrollment, substantiating the child's financial dependence on
employee, provided that the child:
Lives with employee for more than 50 percent of time, or is a full-
time student,
AND
Is dependent on employee for more than 50 percent of the
child's support.
CalHR 781 Page 4 of 5 (rev 5/2020)
Section II
Employee Acknowledgement of Obligations
Employee must initial all sections, certifying under penalty of perjury that:
All of the above information provided by me is true and correct to the best of my knowledge.
I provided the required documents to substantiate the relationship of my enrolled dependent(s).
I understand that additional information and supporting documents may be requested, as necessary, to
substantiate dependent eligibility for health, dental, and/or vision benefits.
I agree to notify my departmental HR office in writing, within 60 days, upon the dissolution of a
marriage or domestic partnership, when a parent-child relationship ends, or a change in the
eligibility of my dependent(s) occurs.
I understand that making, or causing to be made, any knowingly false material statement or
material representation, or knowingly failing to disclose a material fact (e.g., divorce), or to
otherwise provide false information with the intent to use it, may result in possible employment
action up to and including termination of employment.
I agree that I may be required to reimburse my employer, the health, dental, or vision benefit plan,
and the CalPERS system for expenditures made for medical claims, processing fees,
administrative expenses, and attorney's fees on behalf of any family member, if any of the
documents submitted is found to be inaccurate or fraudulent.
I agree that a review of eligibility can occur at any time.
Employee Signature
Date
Section Ill
Certification by Human Resources Staff
HR Representative must initial all sections, certifying under penalty of perjury that:
I am a duly appointed and qualified representative of the department stated on Page 1.
I reviewed the employee's health, dental, and/or vision enrollment form(s) and supporting
documents to verify the eligibility of the dependent(s).
I informed employee of the requirement to notify their employer in writing, within 60 days, upon the
dissolution of a marriage or domestic partnership, when a parent-child relationship ends, or a
change in a dependent eligibility occurs.
I informed employee that they may be required to reimburse their employer, the health, dental, or
vision benefit plan, and the CalPERS system for expenditures made for medical claims, processing
fees, administrative expenses, and attorney's fees on behalf of any family member, if any of the
documents submitted is found to be inaccurate or fraudulent, and that a review of eligibility can
occur at any time.
I retained copies of the employee's health, dental, and/or vision enrollment form(s) and all
supporting dependent eligibility verification documents in the employee's Official Personnel File.
I will provide a copy of this completed and signed Checklist to the employee.
Based on the information provided and review of the documentation, I approve enrolling the
dependent(s).
HR Representative Name/Title
HR Representative Signature
Date
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CalHR 781 Page 5 of 5 (rev 5/2020)
Privacy Notice
This notice is provided pursuant to the Information Practices Act of 1977.
The information on this form is requested pursuant to Government Code sections 1151 and 1153, Internal
Revenue Code sections 6011 and 6051, Code of Federal Regulations section 404.1256, and the Social
Security Act, title II, section 218.
The information collected will be used and maintained by State of California agencies and departments for
administering health, dental, and vision benefits.
The submission of all information requested is mandatory unless otherwise noted. If you fail to provide the
information requested, your appointing authority (state agencies and departments) will not be able to
verify your dependent eligibility. Individuals should not provide personal information that is not requested
or required on this form.
Disclosure and Sharing
The privacy of your personal information is important to us. State agencies and departments will not share
your personal information without your permission or consent, but may share them under the following
circumstances:
1.
Other state agencies require the information to administer and process your eligibility verification,
and/or make requested changes to an existing enrollment.
2.
You give us permission and we have your consent.
3.
We may release information to a party with legal authority, such as a subpoena.
Privacy Policy
The information collected on this form is subject to the limitations in the Information Practices Act of 1977
and state policy. For more information on how we care for your personal information, please read the
Privacy Policy of the state agency or department in your request.
You can review CalHR's Privacy Policy at http://calhr.ca.gov/pages/privacy-policy.aspx.
Access to Your Information
We want to ensure we have accurate information about you. In general, you have the right to review your
personal information that we have. If you have any questions or concerns, please contact the human
resources office of the state agency or department in your re
quest.
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Completed 22 February 2022

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