Page 5 - 2018 Carlstar Benefit Guide
P. 5
BENEFITS ENROLLMENT • 20185
Dependents Eligible for Coverage Under the
Medical/Dental/Vision Plans
1. Your legal spouse
2. Your (or your spouse’s) child under the age of 26 (without regard
to residency requirements, inancial support, or student status)
which meets one of the following criteria Initial Eligibility
A. Your biological child Enrollment Period
Your initial eligibility enrollment
B. Your stepchild period for coverage under The Carlstar
C. Your adopted child or a child placed with you for adoption Group Beneits Program ends 31 days
immediately following your eligibility
D. A child for whom you are an appointed legal guardian date. If you do not apply for coverage
E. Disabled adult child(ren) within your initial eligibility period
(through the enrollment process), you
may only apply for coverage:
Dependent Verification Affidavit X During the next annual
Please use the Dependent Veriication Afidavit provided separately enrollment period
to list the individuals you want to enroll in The Carlstar Group’s X Within 31 days of a qualiied
sponsored medical/dental/vision plans as your dependents. The status change as described in the
deinition of eligible dependents are listed above. Please list each next section
dependent and their social security number and To initiate a qualiied status change, go
check the appropriate box(es) for each dependent. to www.portal.adp.com or contact your
Human Resources Department and
provide documentation of the change.
You must make all changes within 31
days of the date of the change in status.
*Should you have a dependent eligible
for coverage under the medical plan
who does not have a SSN, you can still
enroll them on the enrollment system.
Dependents Eligible for Coverage Under the
Medical/Dental/Vision Plans
1. Your legal spouse
2. Your (or your spouse’s) child under the age of 26 (without regard
to residency requirements, inancial support, or student status)
which meets one of the following criteria Initial Eligibility
A. Your biological child Enrollment Period
Your initial eligibility enrollment
B. Your stepchild period for coverage under The Carlstar
C. Your adopted child or a child placed with you for adoption Group Beneits Program ends 31 days
immediately following your eligibility
D. A child for whom you are an appointed legal guardian date. If you do not apply for coverage
E. Disabled adult child(ren) within your initial eligibility period
(through the enrollment process), you
may only apply for coverage:
Dependent Verification Affidavit X During the next annual
Please use the Dependent Veriication Afidavit provided separately enrollment period
to list the individuals you want to enroll in The Carlstar Group’s X Within 31 days of a qualiied
sponsored medical/dental/vision plans as your dependents. The status change as described in the
deinition of eligible dependents are listed above. Please list each next section
dependent and their social security number and To initiate a qualiied status change, go
check the appropriate box(es) for each dependent. to www.portal.adp.com or contact your
Human Resources Department and
provide documentation of the change.
You must make all changes within 31
days of the date of the change in status.
*Should you have a dependent eligible
for coverage under the medical plan
who does not have a SSN, you can still
enroll them on the enrollment system.
