1

Status change form: Add or drop health, dental, and/or vision coverage

Before you fill out this form:• This form is only for adding or dropping coverage due to an IRS-approved life event (see page 2). If

you or your dependent(s) have not experienced an IRS-approved life event, you will need to wait until the next open enrollment period or for a life event to occur to make changes.

• We automatically remove dependents age 26. You don't have to fill out a form to do that.

Directions:1. Check to see which required documentation you must submit (on page 2).2. Complete this form. Signature required at top of page 3.3. Scan your required documentation.4. Email this form and required documentation to HR.Benefits@hennepin.us within 30 days of your event.

Employee name: Employee ID:

Email: Phone #:

List all affected family members: Include yourself, if applicable. Use second form to add more than six individuals.

Last name First name Relationship Social Security number

Date of birth Gender

M F

Add coverage: Health Dental Vision Drop coverage: Health Dental Vision

M F

Add coverage: Health Dental Vision Drop coverage: Health Dental Vision

M F

Add coverage: Health Dental Vision Drop coverage: Health Dental Vision

M F

Add coverage: Health Dental Vision Drop coverage: Health Dental Vision

M F

Add coverage: Health Dental Vision Drop coverage: Health Dental Vision

M F

Add coverage: Health Dental Vision Drop coverage: Health Dental Vision

Hennepin County Human Resources – Benefits Division HR.Benefits@hennepin.us | 612-348-7855

2

Event Required documentationMarriage • Marriage certificate

If adding a stepchild: • Copy of child’s state-issued birth certificate naming your spouse as child’s parent

Divorce or legal separation

• Court documentation with both parties’ full names and date of final decree is filedwith the court.

• Ex/spouse address:

Birth/ adoption

• Copy of child's state-issued birth certificate, official birth record, Minnesota voluntaryrecognition of parentage form, or adoption papers naming you as parent. Hospitalforms or documents are not accepted

If adding spouse: • Copy of your marriage certificate

AND• Document dated within the last 60 days showing current relationship with spouse,

such as household bill, lease/mortgage, or bank accountOR

• Front page of your most recent federal tax return

Grandchild • Grandchild’s state-issued birth certificate naming your child as parentAND

• Your child’s state-issued birth certificate naming you as parentAND

• Copy of your most recent tax return showing grandchild as your dependent. Ifgrandchild is a newborn, notarized letters signed by both parents giving you the rightto claim this child on your taxesAND

• Document dated within the last 6 months establishing the grandchild lives with you,such as school records or medical bills

Loss/gain of employer health/ dental/vision coverage due to spouse or dependent change in employment

• Letter from employer listing the names of all covered persons, the benefit coverageeach person has, and the effective date of the coverage change

If adding spouse: • Copy of your marriage certificate

AND• Document dated within the last 60 days showing current relationship with spouse,

such as household bill, lease/mortgage, or bank accountOR

• Front page of your most recent federal tax returnIf adding child:

• Copy of state-issued birth certificate naming you as parent

Loss/gain of Medical Assistance (MA) coverage

• Letter from your county indicating date coverage ended or startedIf adding child:

• Copy of state-issued birth certificate naming you as parent

If adding spouse: • Copy of your marriage certificate

AND• Document dated within the last 60 days showing current relationship with spouse,

such as household bill, lease/mortgage, or bank accountOR

• Front page of your most recent federal tax return

Medicare • Proof of Medicare coverage showing effective date

Hennepin County

3 Human Resources – Benefits Division HR.Benefits@hennepin.us | 612-348-7855

Date:

Signature

Employee Signature:

Learn how to sign forms electronically, or print a hardcopy, sign, and scan this form.

When change will take effect

Qualifying event Effective dateMarriage First of the month following marriage Divorce/legal separation First of the month following date divorce/separation is filed with the court Birth/adoption Date of birth / placement in home Death First of the month following event Employment change, Medicare, or grandchild

If adding coverage, first day after loss of previous coverage (no coverage gap) following receipt of form and documentation.

If dropping coverage, first of the month following receipt of form and documentation.

Loss of Medical Assistance (MA) coverage

First of the month following date of loss of coverage

Eligible dependents: • Legal spouse• Biological or adopted child to age 26• Stepchild of employee to age 26• Foster child (legal guardianship)• Grandchild residing with employee and a federal tax dependent• Child (qualified medical child support order) as the term is defined under Section 609 of the Employee

Retirement Income Security Act (ERISA) and its implementing regulations, which are enforceableagainst an enrollee

• Disabled child – a dependent child who meets the plan definition of “disabled dependent child”. Thehealth and/or dental plan will make the determination of disability.

o Preferred One (health plan): 763-847-4477o HealthPartners (dental plan): 952-883-5000

Health Dental Vision

For office use only

Approved by:

Date:

Effective date:

Add:

Drop: Health Dental Vision