Page 6 - City of Newport City BG- Full Time

Dependent Eligibility Verification

All employees adding/removing dependents must submit documentation to verify their dependent’s eligibility and/or
qualifying life event. The following chart is an easy guide to what documents must be submitted along with the
health enrollment/change form. Annual elections processed during open enrollment through Employee Self Service
(ESS) do not require enrollment forms.

State of
Marriage California Birth Certificate
Enrollment or Certificate of Social Security
Form Required Certificate Domestic Adoption Number
Required Partner (DP) Required
Registration

Employee only • •

Employee & Spouse • • •

Employee & Domestic
Partner (DP) • • • •

Employee & Children • • •

Employee, Spouse/DP &
Children • • • • •

You are responsible for ensuring that the health enrollment information about you and your family members is
accurate, and for reporting any changes in a timely manner. If you fail to maintain current and accurate health
enrollment information, you may be liable for the reimbursement of health premiums and costs of health care
services incurred during the entire ineligibility period.

For example, if your divorce or dissolution occurred in 2019, yet you did not report it until 2020, your former
spouse or domestic partner would be retroactive canceled from coverage effective the first of the month following
the divorce or dissolution.

On page 5, you will find a detailed list of qualifying life events, which must be reported to the HR department so
we can make the appropriate change to your health coverage. Qualifying life events changes must be made
within 60 days from the date of the event. Proper documentation is required, such as a copy of the
marriage/domestic partnership certificate, birth/adoption certificate, or divorce/dissolution of domestic partnership
decree.

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