FOR INTERNAL USE ONLY: Health Group # Dental Group # 000405-
Date: Medica: Delta Dental: PERA Life:
Payroll: New World: 121 Benefits QB: Deferred Comp:
Auditor: MN Life: 121 Benefits SPM: Flex Spending:
You have 31 days from your date of hire or from the "Date of Event" listed under the "Reason for Enrollment or Change" section to
complete and submit this form to the City of Duluth's Human Resources Office. Once you complete and submit this form, it will be
recorded as your election until the next Open Enrollment. You will not be able to make changes to your enrollment elections unless you have a
qualified status change.
SECTION B: Reason for Enrollment or Change
New Employee
Date of Hire:
Check all that apply: Documentation is required for all qualifying status-change events
Change in employment status (e.g., a change affecting eligibility for health and/or dental benefits)
Spouse and/or child loses other coverage
Child is ineligible (refer to "Dependent Eligibility Requirements")
Judgment or decree (i.e., Qualified Medical Child Support Order or Legal Guardianship)
Other reason (please list):
Date of Event:
SECTION C: Health Plan Election Comprehensive Hospital / Medical Benefit Plan
Coverage Election: Single Family (Full-Time Employees Only)
I decline health care coverage and have enclosed proof of other health care coverage, which meets the Minimum Essential
Coverage (MEC) requirement under the Affordable Care Act.
SECTION D: Dental Plan Election
Dental Plan Election:
Employee Employee + Spouse Employee + Child Family Waive Dental (Part-Time Employees Only)
Coverage Election:
Low Option - $1,000 Annual Benefit High Option - $2,000 Annual Benefit
SECTION A: Employee Information
Full Name: Social Security Number:
Mailing Address: City: State: Zip:
Home Phone: Cell Phone: Work Phone:
Email Address: Date of Birth:
Department: Date of Hire:
Division: Bargaining Unit: Not Represented (NREP)
Gender: Female Marital Status: Single Widowed Status:
Basic LELS
Confidential Police
Supervisory Fire
Male Married Legally Separated Part-Time (Hours/Week: )
Benefits Effective Date:
First Payroll Deduction:
Clear Section A
Clear Section B
Clear Section C
Clear Section D
Plan Requirements for Submitting Your Enrollment Change Request If you experience a qualifying family status change event, you can enroll or remove family members from your
health and/or dental coverage, or make a change to your current Flexible Spending Account election within 31 days from the date of the event (e.g., the day you marry, the birth date of
your newborn child, etc.). Human Resources must receive your benefit election change request within 31 days from the date of the qualifying family status change. If you miss the 31-day
window for submitting your enrollment forms, you must wait until the Open Enrollment period to change your benefit elections.
"Consistency Rule" For an election change to be permitted, a qualifying event must have occurred and the election change request must be consistent with the event. For example, if
you have single health and dental coverage and you subsequently get married you may add your spouse to your health and/or dental coverage within 31 days from the date you marry.
Dependent Eligibility Requirements
Your family members may be covered under the Duluth JPE Trust sponsored health and welfare benefit plans as long as they meet the eligibility requirements:
Spouse — Legally married or legally separated spouse, or Dependent Child — Birth through age 25 (up to the child's 26th birthday):
- An eligible child can include your unmarried or married biological child, legally adopted child or child placed for the purposes of adoption, foster child, stepchild or any other child who
state or federal law requires be treated as a dependent.
- A grandchild you claim as an exemption on your federal income tax return and who is financially dependent upon you.
- A child of the employee who is required to be covered by reason of a Qualified Medical Child Support Order (QMCSO).
Employee Responsibility for Completing Forms
When a qualifying family status change event occurs, you are responsible for completing the benefit enrollment form(s) to:
1.) Add or cancel dependent medical and/or dental coverage;
2.) Make changes to your Flexible Spending Account (medical and/or dependent daycare);
3.) Make changes to your life insurance coverage, beneficiary election, PERA Pension Benefit, and/or Deferred Compensation Plan(s).
SECTION E: Dependent Information
Complete this section if you wish to add or cancel dependent coverage. For qualifying status-change events, please attach supporting documentation.
Full Name of Dependent Social Security Number Date of Birth Gender Relationship to Employee Health Dental
SECTION F: Additional Insurance Information – Medicare, Medicaid, or Other Coverage
Complete this section and attach a copy of the insurance card(s) if you or any covered dependents are eligible for Medicare, Medicaid, or other insurance.
Full Name of Insured
Coverage Type
(Medicare, Medicaid, or other insurance)
Policy Number
Medicare Part A
Effective Date
Medicare Part B
Effective Date
SECTION G: Authorization and Signature
I hereby certify by my signature on the enrollment form that the foregoing information provided by me is true and correct, and that I have read and accept the
conditions described in the enrollment material. I acknowledge having read the information provided to me and agree to all of the terms as defined by the
plans I have selected, and I authorize the required deduction (if any) from my wages. By signing this form, I attest that I have reviewed the "Dependent
Eligibility Requirements" and that the information I am submitting is true and accurate. I understand that providing false information or omission of relevant
information on this form may result in the denial of claims, cancellation or rescission of coverage, and the City of Duluth or Duluth Joint Powers Enterprise
Trust may be required to take action to recover funds expended due to fraud or fiscal misconduct. I also understand that it is my duty to notify the City of
Duluth Human Resources Office of any changes provided by me on this form, including changes to the eligibility status of my dependents.
Employee Signature Date
A family status change is a personal event that warrants a review of employee benefits. The summary below explains how your benefits may be affected and the actions you
should take for the following family status change events:
• Marriage, Divorce, Annulment
Child's loss of eligibility for coverage
Death of an eligible family member
Entitlement to Medicare or Medicaid
Judgment or decree (i.e., Qualified Medical Child Support Order)
Birth, Adoption or placement for adoption, Gain or Loss of a stepchild or legal ward to your family
Change in employment status (gain or loss of employment or a change that affects health and dental benefit plan eligibility)
Clear Section E
Clear Section F
Clear Section G
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