Office of Human Resources
Benefits section – MS 118
781-736-4467
781-736-4466(f)
HR Use Only Emlp ID: 100 __ __ __ __ __
P.O. Box 549110
Waltham, MA 02454
benefits@brandeis.edu
PS: __/___/_______
FAC__ EXS __ NEX __ PD __
H. Prev. ___________ D. Prev. ___________
QUALIFIED STATUS CHANGE FORM HEALTH/DENTAL INSURANCE
1. PERSONAL INFORMATION
Last Name
First Name
Address
City
State
Zip
Marital Status
email
2. BENEFIT PLAN ELECTIONS
Enrollment is pending until all paperwork is received.
Coverage Effective Date Rules:
Required Documentation for coverage:
Coverage begins on change effective date
Marriage Certificate Proof of other Coverage/Termination Divorce Decree
Coverage must be elected and documentation submitted within 31 days of status change Birth Certificate/Adoption/Guardianship paperwork Death Certificate
Reason for submission: ☐ Change in marital status ☐ Birth/Adoption ☐ Gained/Lost Coverage ☐ Divorce/Separation ☐ Death of dependent ☐ Dependents no longer eligible
☐ Unpaid Leave of Absence ☐ Relocate in/out of service area
Medical Plan – Effective Date: ____________
Dental Plan – Effective Date: _____________
Medical -Action
☐ Enroll
☐ No Change
☐ Add dependents
☐ Remove dependents
☐ Waive Medical Coverage*
Medical Insurance 2015
☐ Tufts PPO
☐ Tufts Premium HMO/EPO
☐ Tufts Value HMO/EPO
☐ Individual
Dental – Action
☐ Enroll
☐ No Change
☐ Add dependents
☐ Remove dependents
☐ Waive Dental coverage
☐ Family ☐None
Dental Insurance 2015
☐ Dental PPO Plus Premier
☐ DeltaCare
☐ Individual ☐ Family ☐None
* If I choose to waive health care coverage, I acknowledge the Brandeis University offers employer sponsored health care plan coverage and requires all benefits eligible faculty and staff to elect or waive
such coverage. I do not wish University sponsored coverage. I acknowledge my full responsibility medical/hospitalization and outpatient expenses of any kind when incurred and release and discharge
Brandeis University, its employees and agents from and obligations I may incur as a result of any illness or injury. ____________________________________________________
________________
Signature
Date
Dental
Health
First Name
(List last name only if different from
employee’s last name)
Date of
Birth
Social Security
Number**
(mm/dd/yyyy)
Gender
3. PRIMARY CARE PROVIDER INFORMATION & DEPENDENT COVERAGE - Please list all dependents to be covered
Choose a Primary Care Provider for each member for the plans below (required)
Current
Current
Medical (HMO’s only)
PCP ID#
DeltaCare (Only)
patient?
patient?
(Dr. first and last name)
Facility ID#
Y N
Y N
Employee
Spouse
Child
Child
Child
** Group health insurance provider requires Social Security Information according to Mandatory Reporting Law (Sec.111 of Public Law 110-173).
4. ACKNOWLEGMENT & SIGNATURE
I certify that all the information supplied on this form is true and complete. I acknowledge that I have received the Brandeis University Benefits and Services handbook and have been given the opportunity to enroll in the Brandeis
benefit plans. I authorize Brandeis to reduce my pay by the amount of any required contributions on a pre-tax basis for the coverage selected. I also understand my coverage elections on this form cannot be revoked or modified
during the year unless I have a qualifying change in status as defined by the IRS; I may, however change my coverage election during the next open enrollment period. I understand that the benefits for which I (we) will be eligible are
those described in the applicable insurance certificate, summary plan description or benefit documents.
By enrolling, I understand and agree that if I or any of my enrolled dependents obtain a health care benefit or payment that I (we) are not entitled to receive, or if I (we) knowingly present a claim that contains a false statement, I
(we) can be liable for the full amount of the health/dental care benefit or payment made and for reasonable attorney’s fees and costs, including the cost of the investigation.
Employee Signature
Date Benefit
Staff Signature
Date