Life Status/Open Enrollment Change 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
Zip Code
Date of Hire
Work Phone
Home Phone
Email/Access ID
Please check one: Open Enrollment Change Life Status Change Event
Please read the following information carefully:
If you experience a qualifying Life Status Change Event as listed below, you are allowed to make certain changes to your
benefits. Generally, changes to enrollment are interlocking, meaning changes are applied to all active plans (medical, vision,
and/or dental). A Life Status Change Event is the only time that you are allowed to make a benefit change outside of the annual
Open Enrollment period. When adding a dependent, coverage will begin the first of the month following the event date or on
the date of birth or adoption. When terminating a dependent, coverage will end the last day of the month following the event
date. For further Life Status Change Event information: hr.wayne.edu/tcw/health-welfare/section125-changes.pdf
This form must be received with required Dependent Supporting Documentation by the HR Service Center within 30 days of
the qualifying Life Status Change Event or during the Open Enrollment period. For terminations during Open Enrollment,
Dependent Supporting Documentation is not required. Dependent Supporting Documentation requirements are online:
If you are not currently enrolled in a medical, vision or dental plan and/or you are changing plans due to a Life Status Change
Event, you must complete this form and the
Employee Benefit Enrollment Form
Qualifying Life Status Change Event (Check one):
Marriage or Other Eligible Person
Divorce or Legal Separation
Birth, adoption or placement for adoption of a child
Judgement, decree or court order
Medicare entitlement
Date of Event: _____________________________________
Check One:
Add Coverage Terminate Coverage
Dependent Information: (only include information for individuals to be added or terminated from existing coverage)
Last Name First Name
Social Security
Number (Required)
HMO must complete:
Primary Care Physician
Name & ID #
Office Use Only
*Relation Code: S=Employee, M=Spouse, C=Child, O=Sponsored Dependent, H=Disabled Dependent, P=Other Eligible Person
I have attached the required supporting documentation. Authorization: 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 certify that the information provided is true and correct. I authorize the
university to change my benefit enrollments and to adjust my payroll deduction in accordance with the changes I have requested.
Employee Signature
Attach required documentation and return to:
HR Service Center, 5700 Cass Ave., Suite 3638, Detroit, MI 48202; Fax: 313-577-0637
click to sign
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