Fill - Free fillable Employee Benefit Enrollment Form (Wayne State University) PDF form

Dependent Eligibility and Supporting Documentation Requirements

When sending in forms, be sure to include the following documentation:

Office Use Only:

hr.wayne.edu/tcw

Employee Benefit Enrollment Form

Security Alert: Do not send this form via E-mail

Employee Name (Last, First) Please print

Banner ID

Social Security Number

Date of Birth

Street Address

City

State

Zip Code

Date of Hire

Work Phone

Home Phone

Email/Access ID

Check one:  New Hire  Open Enrollment Change  Life Status Change Event (attach Life Status/Open Enrollment Change Form)

Pre and Post Tax Medical Deductions: Check Only One

 I elect PRE-TAX deductions (Default) (A)  I elect POST-TAX deductions (B) Office Use

Only

Eff Date: _____

DOH: ________

E Class: _______

Med: ________

Dental: _______

Vision: _______

Life: _________

LTD: _________

Sup Life: _____

Dep Life: _____

Medical Insurance: Check Only One

 Total Health Care HMO (BTA/BTB)

 Community Blue PPO (BEA/BEB)

 Health Alliance Plan HMO (BCA/BCB)

 Blue Cross Blue Shield (BAA/BAB)

 Blue Care Network HMO (BBA/BBB)

 Cash In Lieu of Medical (BCM/L) MUST submit Cash In

Lieu of Medical Form and proof of other group coverage

to receive cash benefit.



Waive Medical Coverage (BE9)

For costs and descriptions: hr.wayne.edu/tcw/health-welfare/med-insurance

Vision Insurance: Check Only One  Basic (BVS)  Enhanced Buy-Up (BVE)  Waive Vision (BV9)

Note: Basic vision insurance is bundled with medical insurance for all eligible groups. If you elect medical and are

eligible, you will receive Basic vision coverage unless you elect Enhanced Buy-Up.

Voluntary Vision Insurance:

Non-Medical Plan Participants Only

For those electing Cash In Lieu of Medical coverage, complete the Voluntary Vision Plan Enrollment Form to elect a

voluntary vision plan. To learn more: hr.wayne.edu/tcw/health-welfare/vision-plan

Dental Insurance Check Only One  Delta Dental (BGA)  Waive Dental Coverage (BG9)

Voluntary Dental Insurance:

Non-Medical Plan Participants Only

For those electing Cash In Lieu of Medical coverage, complete the Voluntary Dental Plan Enrollment Form to elect a

voluntary dental plan. To learn more: hr.wayne.edu/tcw/health-welfare/dental-insurance

Life/AD&D Insurance Complete the Basic and Supplemental Life/AD&D

Enrollment/Change F

orm to designate

beneficiary(ies) – Basic Life is employer paid. To learn more: hr.wayne.edu/tcw/health-welfare/life-insurance

Dependent Information: Complete table for self and each dependent you wish to enroll. If you are enrolling in an HMO (HAP, BCN, THC), you

MUST select a Primary Care Physician for yourself and each dependent. Valid Social Security Numbers and required documentation must be submitted

for all dependents added to the plans. The university reserves the right to request additional documentation to verify eligibility of dependents.

Last Name First Name

Social

Security

Number

(Required)

Sex

(M/F)

DOB (M/D/Y)

Relation

Code*

Attach

Required

Documentation

HMO must complete:

Primary Care Physician

Name & ID #

Office Use

Only

(Self)

N/A

1040/Other

Birth Certificate

*Relation Code: S=Employee, M=Spouse, C=Child, O=Sponsored Dependent, H=Disabled Dependent, P=Other Eligible Person

The information listed above is correct to the best of my knowledge. I authorize bi-weekly deductions, if appropriate, for insurance based on the current

rates and any future rate increases. I certify that the names above are legal and eligible dependents. I understand that falsely certifying eligibility

requirements in any respect could result in disciplinary action, that the university may request additional eligibility evidence, that I will be liable for all

expenditures for coverage and benefits plus any administrative expenditure and that I must notify the HR Service Center immediately when a dependent

becomes ineligible. I authorize release of the information listed above to the insurance plan I have selected for the purpose of obtaining coverage. The

information will be provided to the insurance plan in electronic format. I have provided required documentation to support proof of dependency.

Employee Signature

Date

Attach required documentation and return to:

HR Service Center, 5700 Cass Ave., Suite 3638, Detroit, MI 48202; Fax: 313-577-0637

Relationship Eligibility Requirements Documentation to Submit

Legal Spouse*

• Legal spouse of the Employee

Employee’s most current year’s filed federal income

tax return Form 1040 – the first page only (financial

information should be blacked out).

For marriages occurring in 2020, only a copy of marriage

certiﬁcate is required

Other Eligible

Person (OEP)

A person who is:

• An adult, age 26 or older; and

• Currently resides in the same residence as the

employee and has done so for 18 continuous

months prior to the individual’s enrollment,

other than as a tenant; and

• Not a dependent of the employee as defined

by the IRS; and

• Not related by blood or marriage.

BOTH of the following documents:

• Proof of joint obligation for the last 18 months:

Examples include:

• A mortgage statement;

• Bank statement;

• Property bill;

• Monthly bill from a rental/lease agreement; AND

• Copy of Driver’s License or State ID Card – must

reflect the same address as WSU employee.

Children Under

Age 26

• Child(ren) by birth;

• Stepchild(ren);

• Legally adopted child(ren) or child(ren)

placed in your home for final adoption;

• Child(ren) under legal guardianship; or

• Child of OEP.

ONE of the following documents:

• Birth certificate listing parents or adoption paperwork;

issued by a State or County; or

• Employee’s most current year’s filed federal income

tax return Form 1040 – the first page only listing the

dependent children (financial information should be

blacked out); or

• Qualified Medical Child Support Order (QMCSO)

which requires child support for benefit coverage; or

• Court paperwork for legal guardianship.

Principally

Supported

Children

Under Age 19

A child who is:

• Not the employee’s child by birth or

marriage; and

• Related to the employee by blood or

marriage; and

• Claimed as a dependent of the employee

on their most recent income tax return.

The following document:

• Employee’s most current year’s filed federal

income tax return Form 1040 – the first page only

(financial information should be blacked out).

Disabled Children

Over Age 26

• An unmarried child who became disabled

before reaching age 26 and is incapable of

self-sustaining employment by reason of

mental or physical handicap.

BOTH of the following documents:

• The required documentation for a child under age 26

listed above AND

• Any documentation verifying a permanent disability

that began before the child attained age 26.

Fill Online, Printable, Fillable, Blank Employee Benefit Enrollment Form (Wayne State University) Form

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Fillable Employee Benefit Enrollment Form (Wayne State University)

Fill Online, Printable, Fillable, Blank Employee Benefit Enrollment Form (Wayne State University) Form

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