OFFICE USE ONLY: EE# Event Date: Effective Date: BW M
REASON FOR CHANGE:
Note: Change must be made within 31 days of qualifying event. Documentation required. See EBC for details.
[ ] Birth or Adoption [ ] Marriage [ ] Loss of Other Group Coverage [ ] Death of Dependent
[ ] Medical Support Order [ ] Divorce [ ] Obtained Other Coverage [ ] Other _____________
EMPLOYEE INFORMATION
Social Security #: Name: Last First Middle
COVERAGE CHANGES
Dental & Vision Plans - make NEW coverage election below, then indicate dependent information in box:
Dental HMO [ ] Cancel [ ] Employee Only [ ] Employee/Child(ren) [ ] Employee/Spouse [ ] Employee/Family
Dental PPO [ ] Cancel [ ] Employee Only [ ] Employee/Child(ren) [ ] Employee/Spouse [ ] Employee/Family
Vision [ ] Cancel [ ] Employee Only [ ] Employee/Child(ren) [ ] Employee/Spouse [ ] Employee/Family
DEPENDENT INFORMATION (for dental and vision coverage changes only)
Name (last, first, middle)
M F
M F
M F
M F
Flexible Spending Accounts (FSA's)
Medical FSA: $ (per plan year) Dependent Care FSA: $ (per plan year)
AUTHORIZATION
Signature:
Date:
I certify that the benefit changes requested above meet Section 125 Qualified Family Status Change requirements. I understand that
form(s) and documentation must be submitted to the Garland ISD Benefits Department within 31 days of the qualifying event. I authorize
the necessary payroll deductions for my change(s). Additional deductions from or adjustments to my next paycheck may be required if a
pay period has been missed.
GARLAND ISD BENEFITS CHANGE FORM
Add
Social Security #
Date of Birth
Gender
Relationship
Drop
Last, First Middle
Male
Female
Female
Female
click to sign
signature
click to edit
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