Page 20 - 2015 Enrollment Guide
P. 20
Beneits Guide
Dependent Eligibility Requirements and
Documentation Required for Dependents
Type of Dependent Eligibility Requirements Documentation you need to provide
Photocopies are acceptable
Spouse X Must be legally married to the employee X Copy of most recently iled federal tax return (irst
Dependent V
X Common law spouses are NOT eligible (even and last pages only; please black out earnings
where common law is recognized) information)
OR
X Marriage certiicate AND proof of inancial
interdependence (2)
Domestic Partner X Same or opposite-gender domestic partners X Afidavit of Domestic Partnership AND
(2)
X Must meet all criteria outlined in the Afidavit X Copy of most recently iled federal tax return (irst
eriication
of Domestic Partnership form and last pages only; please black out earnings) OR
X Proof of inancial interdependence (1)
Biological Child X Under age 26 X Birth Certiicate showing you as the child’s parent
OR
X If under 6 months hospital certiicate with birth date
Adopted Child X Under age 26 X Oficial court/agency placement paper
OR
X Certiied court-approved adoption papers
Step-Child X Under age 26 X Birth Certiicate showing your spouse as the child’s
parent
Domestic Partner’s X Under age 26 X Birth Certiicate/adoption papers showing your
Biological or domestic partner as the child’s parent
Adopted Child
AND
X Address veriication showing child’s address is same
as employee’s
Child Covered X Order must be a Qualiied Medical Child X Judgment, order, decree that meets the
Under a Qualiied Support Order (QMSCO) requirements of a QMSCO
Medical Child
Support Order
(QMCSO)
Handicapped Child X Must be incapable of self-sustaining X Application for Extended Coverage
Age 26 or Older employment because of physical handicap, AND
mental retardation, mental illness, or mental X Birth/adoption/guardianship Certiicate showing
health disorder you or your spouse/domestic partner as the child’s
X Dependent on the employee for a majority of parent
inancial support and maintenance and lives
with you for more than half the year
X Was covered under the Plan before age 26
(1) Proof of inancial interdependence can be a current mortgage statement, bank statement, property tax statement, or lease/rental agreement.
These documents must be dated no earlier than January 1, 2014. Please black out unnecessary information.
(2) The Afidavit of Domestic Partnership and Application for Extended Coverage forms are available on the Benetrac system.
20
Dependent Eligibility Requirements and
Documentation Required for Dependents
Type of Dependent Eligibility Requirements Documentation you need to provide
Photocopies are acceptable
Spouse X Must be legally married to the employee X Copy of most recently iled federal tax return (irst
Dependent V
X Common law spouses are NOT eligible (even and last pages only; please black out earnings
where common law is recognized) information)
OR
X Marriage certiicate AND proof of inancial
interdependence (2)
Domestic Partner X Same or opposite-gender domestic partners X Afidavit of Domestic Partnership AND
(2)
X Must meet all criteria outlined in the Afidavit X Copy of most recently iled federal tax return (irst
eriication
of Domestic Partnership form and last pages only; please black out earnings) OR
X Proof of inancial interdependence (1)
Biological Child X Under age 26 X Birth Certiicate showing you as the child’s parent
OR
X If under 6 months hospital certiicate with birth date
Adopted Child X Under age 26 X Oficial court/agency placement paper
OR
X Certiied court-approved adoption papers
Step-Child X Under age 26 X Birth Certiicate showing your spouse as the child’s
parent
Domestic Partner’s X Under age 26 X Birth Certiicate/adoption papers showing your
Biological or domestic partner as the child’s parent
Adopted Child
AND
X Address veriication showing child’s address is same
as employee’s
Child Covered X Order must be a Qualiied Medical Child X Judgment, order, decree that meets the
Under a Qualiied Support Order (QMSCO) requirements of a QMSCO
Medical Child
Support Order
(QMCSO)
Handicapped Child X Must be incapable of self-sustaining X Application for Extended Coverage
Age 26 or Older employment because of physical handicap, AND
mental retardation, mental illness, or mental X Birth/adoption/guardianship Certiicate showing
health disorder you or your spouse/domestic partner as the child’s
X Dependent on the employee for a majority of parent
inancial support and maintenance and lives
with you for more than half the year
X Was covered under the Plan before age 26
(1) Proof of inancial interdependence can be a current mortgage statement, bank statement, property tax statement, or lease/rental agreement.
These documents must be dated no earlier than January 1, 2014. Please black out unnecessary information.
(2) The Afidavit of Domestic Partnership and Application for Extended Coverage forms are available on the Benetrac system.
20
