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
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
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
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
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
I authorize the University to collect premium contributions by payroll deduction or otherwise, for remittance to applicable
I have read and agree with the above terms.
BASIC LIFE INSURANCE - METLIFE
FLEXIBLE SPENDING ACCOUNTS
2x’s benefits base salary
Healthcare total for calendar year ______________
Dependent (Day) Care total for calendar year ______________
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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