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P. 4
2017 Benefits Enrollment
Benefit Plan Eligibility and
Coordination of
Benefits Policy Enrollment
If you have a working spouse
who is eligible for coverage under Eligibility
a medical plan through his/her
employer, your spouse is required You will become eligible for insurance on the day you complete the
to enroll in the medical plan waiting period if:
unless your spouse’s employer
requires your spouse to pay You are in a class of eligible employees
100% of the coverage. If your You are an eligible, full-time employee
spouse’s employer does share in
the cost of the medical coverage, You normally work at least 30 hours week
and your spouse does not elect You pay any required contribution
to enroll in his/her employer’s
plan, your spouse will not qualify Documents to Support Dependent Eligibility
for coverage under The Carlstar The Carlstar Group is entitled to perform periodic audits to verify
Group medical plan and any
related claims will be denied. dependent eligibility.
When your spouse is enrolled
in another plan, the plan is You may be required to provide a copy of one or more of the following
considered PRIMARY for your documents to support your dependent’s eligibility.
spouse and all claims should be
submitted to the plan. Marriage certiicate or license
Failure to comply with this policy Birth certiicate for each biological child
will prevent your spouse from Birth certiicate for each stepchild showing your spouse as the child’s
being eligible for or covered by
medical beneits provided by The parent
Carlstar Group group medical Final adoption certiicate
plan. Any misrepresentation(s)
regarding the eligibility or Legal adoption agency or placement certiication
coverage of your spouse Legal document for court-appointed guardianship
may result in your immediate
termination of employment with Dependent Verification Affidavit
The Carlstar Group.
Please use the Dependent Veriication Afidavit provided separately to
list the individuals you want to enroll in The Carlstar Group’s sponsored
medical/dental/vision plans as your dependents. The deinition of eligible
dependents is provided on the following page. Please list each dependent
and their social security number and check the appropriate box(es) for
each dependent.
4
Benefit Plan Eligibility and
Coordination of
Benefits Policy Enrollment
If you have a working spouse
who is eligible for coverage under Eligibility
a medical plan through his/her
employer, your spouse is required You will become eligible for insurance on the day you complete the
to enroll in the medical plan waiting period if:
unless your spouse’s employer
requires your spouse to pay You are in a class of eligible employees
100% of the coverage. If your You are an eligible, full-time employee
spouse’s employer does share in
the cost of the medical coverage, You normally work at least 30 hours week
and your spouse does not elect You pay any required contribution
to enroll in his/her employer’s
plan, your spouse will not qualify Documents to Support Dependent Eligibility
for coverage under The Carlstar The Carlstar Group is entitled to perform periodic audits to verify
Group medical plan and any
related claims will be denied. dependent eligibility.
When your spouse is enrolled
in another plan, the plan is You may be required to provide a copy of one or more of the following
considered PRIMARY for your documents to support your dependent’s eligibility.
spouse and all claims should be
submitted to the plan. Marriage certiicate or license
Failure to comply with this policy Birth certiicate for each biological child
will prevent your spouse from Birth certiicate for each stepchild showing your spouse as the child’s
being eligible for or covered by
medical beneits provided by The parent
Carlstar Group group medical Final adoption certiicate
plan. Any misrepresentation(s)
regarding the eligibility or Legal adoption agency or placement certiication
coverage of your spouse Legal document for court-appointed guardianship
may result in your immediate
termination of employment with Dependent Verification Affidavit
The Carlstar Group.
Please use the Dependent Veriication Afidavit provided separately to
list the individuals you want to enroll in The Carlstar Group’s sponsored
medical/dental/vision plans as your dependents. The deinition of eligible
dependents is provided on the following page. Please list each dependent
and their social security number and check the appropriate box(es) for
each dependent.
4
