Fillable Family Status Change Form (University of Delaware)

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Family Status Change Form (University of Delaware)

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The Family Status Change Form (University of Delaware) form is 3 pages long and contains:

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  • 32 check-boxes
  • 45 other fields

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File type: PDF

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Family Status Change Form
INSTRUCTIONS
• A Family Status Change form (FSC) must be completed if you have experienced a change in family status
(marriage, birth of a child, adoption, divorce, death of a spouse or child, etc.) and would like to make
changes. The completed form must be returned to the HR-Benefits department within 30 days of the event
date. If this form is not received within 30 days, the change in benefit coverage cannot take place until the
next annual open enrollment.
• Please complete pages 2 and 3 of the FSC form (please print) only indicating the name(s) and desired
change(s). The change must be consistent with your status change.
• Specific documentation other than this FSC form may be required for certain changes. Please refer to the
Acceptable Supporting Documentation section below.
• Return the completed form and supporting documentation (if applicable) to the HR-Benefits department:
413 Academy Street or email hrhelp@udel.edu.
• Please contact the Office of Human Resources-Benefits by email (hrhelp@udel.edu) or phone (302) 831-
2171 with any questions about this form or your benefits.
IMPORTANT REMINDERS
• Remember to update beneficiaries for Basic Life Insurance and Retirement benefits.
o MetLife Beneficiary Designation
o TIAA Beneficiary form
o State Pension Personal Information Form (P-1)
ACCEPTABLE SUPPORTING DOCUMENTATION:
Event
Documentation/Forms Required
Change in marital status:
• Marriage
• Marriage Certificate
• Social Security Card
• State of Delaware Spousal Coordination form
• Divorce
• Divorce Decree
Change in number of dependents:
• Birth
• Adoption
• Become a step parent
• Birth announcement/Birth Certificate
• Adoption Certificate
• Aetna -Dependent Coordination form (DCOB)
• Highmark – Dependent Coordination form (DCOB)
• Social Security Card
• Death
• Death Certificate
Change in employment status:
• Employee (part-time, leave of absence)
• Spouse/Dependent child (new employment, leave
of absence, termination of employment, etc.)
• Loss of employment/coverage
• Letter of employment listing the effective date of new health
insurance
1 OF 3
Employees can review their current benefits coverage level in Web Views under Flex Benefits View to ensure
changes are reflected correctly.
Last Revision: 9/2019
Family Status Change Form
Please print all information
Employee Personal Information:
Name: _____________________________________________
Employee ID: ______________________________
Work Phone: ______________________________
Home Phone: ______________________________
Effective Date of Family Status Change: ______________________________
Reason for Family Status Change – Indicate the family status change by marking an “X” in the appropriate box.
Marriage Divorce Death of spouse or dependent
Birth or Adoption of Child Change in Spouse’s employment Change in percent time worked
Change in child’s eligibility Moving out of HMO service area Other _______________________
Explanation Required
Action: Add Coverage Remove Coverage
Dependent Information: If you are removing a dependent, please provide the dependent’s current address:
___________________________ ____________________________ ______________ _______
Street City State Zip
DEPENDENT INFORMATION
Spouse/Dependent Name(s)
Gender
Social Security #
Birth Date
PLAN/COVERAGE LEVEL CHANGES ONLY
MEDICAL
DENTAL
VISION
First State Basic
Aetna CDH Gold
Aetna HMO
Highmark Comprehensive
PPO
Waive
Employee
Empl & Spouse
Empl & Children
Family
MetLife
Waive
Employee
Empl & Spouse
Empl & Children
Family
NVA
Waive
Employee
Empl & Spouse
Empl & Children
Family
2 OF 3
Employees can review their current benefits coverage level in Web Views under Flex Benefits View to ensure
changes are reflected correctly.
Last Revision: 9/2019
Family Status Change Form
Changes During the Year
Please know that you can change your coverage between annual enrollments only if you have a change in status, as defined by
federal
law. A
change in status happens when: you marry, divorce or legally separate; a child joins your family through birth or
adoption; your spouse becomes employed, loses his or her job (full-time employment) or involuntarily loses medical coverage; your
spouse or dependent
child dies;
your dependents become ineligible for coverage; you or your spouse have a change in job status
from full-time to part-time or vice versa; you or your spouse take an unpaid leave of absence; you or your spouse have a significant
change in health coverage due to a change in your spouse's employment. If you have a change in status, you have only 30 days to
change your coverage. Furthermore, the requested change must be consistent with the event.
Spousal Coordination of Benefits Policy
If you are covering your spouse under a University health plan, we also want to share some very important information with you
about the Spousal Coordination of Benefits Policy. This policy affects how health insurance benefits payments are made for a
spouse who
i
s eligible for, but not enrolled in, coverage through their employer. According to this policy, if your spouse works
full-time and would pay 50% or less of the total premium for individual coverage (premium based on the lowest- cost individual
plan available through their employer), s/he must enroll in their employer's health plan. If your spouse meets the above criteria,
but does not enroll in his/her employer's health plan, the University's plan will pay only 20% of allowable charges.
Misinterpretation and/or failure to comply with this policy may have significant financial implications for you. If applicable,
please take a few minutes to read this policy and sign the Spousal Coordination of Benefits policy form. Information on this
form is shared with Statewide Benefits and is used to verify your spouse's access to health insurance. The Spousal Coordination
of Benefits Policy Form can be found on our web site at: https://cob.ben.omb.delaware.gov/
Basic Employee Life Insurance
Please know that you can change your Basic Life coverage between annual enrollments only if you have a change in family status.
Optional Life Insurance
Changes to your Optional Life insurance coverage can be made at any time during the year. In addition, with a change in family
status, you may be eligible to enroll in or increase coverage for one of the Optional Life Insurance options through MetLife.
Please note that certain levels of coverage for yourself and/or your spouse may require that you and/or your spouse provide proof
of good health. If, as a result of the change in family status, you must cancel Optional Life for your spouse or dependent
children, you should contact MetLife directly. To enroll go to: http://www1.udel.edu/metlife-auth. For more information contact
MetLife Customer Service at 1-866-492-6983.
Health Plan Authorization
I understand that rights to service are subject to acceptance of my enrollment and to the terms and conditions specified in the
present contract between the health insurance carrier and the State of Delaware. I certify that all information supplied by me is
true. I, on behalf of myself and my covered dependents, authorize any physician, hospital or any other health care provider to
release
information available
to them concerning any diagnosis, treatment or other health care services they render to me or my
covered dependents to the health insurance carrier or its designee for purposes reasonably related to their contract or as required
by law.
I authorize the University to collect premium contributions by payroll deduction or otherwise, for remittance to applicable
benefit carriers.
I have read and agree with the above terms.
Signature Date
BASIC LIFE INSURANCE - METLIFE
LONG TERM
DISABILITY
FLEXIBLE SPENDING ACCOUNTS
$10,000
$50,000
2x’s benefits base salary
Standard Option
High Option
Healthcare total for calendar year ______________
Waive
Dependent (Day) Care total for calendar year ______________
Waive
3
OF 3
Employees can review their current benefits coverage level in Web Views under Flex Benefits View to ensure
changes are reflected correctly.
Last Revision: 9/2019
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Family Status Change Form (University of Delaware)

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Completed 24 July 2020

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