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Dependent Eligibility Verification
All employees adding or 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.
Enrollment
Form
Marriage
Certificate
Birth
Certificate
State of CA
DP
Registration
Employee only
•
Employee & Spouse
•
•
Employee & Domestic Partner
(DP)
•
•
Employee & Child(ren)
•
•
Employee, Spouse/DP &
Child(ren)
•
•
•
•
For enrollment into any Medical Plan, a copy of all enrollees’ Social Security Card is also required.
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, it may impact dependent eligibility
for health care continuation under COBRA and will result in you incurring liability for the
reimbursement of health premiums or health care services incurred during the entire ineligibility
period.
In the
When You Can Make Changes
section, you will find a detailed list of Qualifying Life Events,
which must be reported to the Department of Human Resources so we can make the appropriate
change to your health coverage. All Qualifying Life Event changes must be made within 30 days
(or 60 days for CalPERS medical plans) 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.
For further clarification, please contact the Department of Human Resources at (408) 730-7490.