Loading
Form preview picture

Get dependent certificate format pdf

CERTIFICATE OF DEPENDENT ELIGIBILITY FORM Municipal Insurance Trust of NC P. O. Box 1310 Raleigh NC 27602 Please answer all questions and return this form to us as quickly as possible to expedite the processing of your claims and/or enrollment in the MIT. You may be required to provide further proof of legal responsibilities for this dependent. by your employer shall rely upon this information as material inducement for the health/life/dental coverage for this child under the certificate issued to the undersigned. Signature of Employee Date. Name of Employee Name of Dependent Child Municipality Employed by SS Date of Birth - / CHECK ALL THAT APPLY TO THIS DEPENDENT This child is my Natural Child Step-Child OTHER explain Legally adopted child Legally placed foster child Submit copy of appropriate court documents to verify proof of eligibility. married attends school full-time at Who has legal custody of this child Name Address Is there a court order making either parent responsible for the child s medical and/or dental expenses No Yes Who Medical expenses Dental expenses Does the child have medical and/or dental coverage other than through this group health plan provided through the MIT No / Yes Medical / Dental Please circle all that apply Please list other coverage Name of policyholder Relationship to child Policy ID of policyholder Name and address of employer I certify that I have responsibility for the welfare and support of this child and/or I am legally responsible for his/her health/life/dental coverage. Name of Employee Name of Dependent Child Municipality Employed by SS Date of Birth - / CHECK ALL THAT APPLY TO THIS DEPENDENT This child is my Natural Child Step-Child OTHER explain Legally adopted child Legally placed foster child Submit copy of appropriate court documents to verify proof of eligibility. married attends school full-time at Who has legal custody of this child Name Address Is there a court order making either parent responsible for the child s medical and/or dental expenses No Yes Who Medical expenses Dental expenses Does the child have medical and/or dental coverage other than through this group health plan provided through the MIT No / Yes Medical / Dental Please circle all that apply Please list other coverage Name of policyholder Relationship to child Policy ID of policyholder Name and address of employer I certify that I have responsibility for the welfare and support of this child and/or I am legally responsible for his/her health/life/dental coverage.

How It Works

dependent certificate form pdf rating
4.8Satisfied
46 votes

Tips on how to fill out, edit and sign Dependency certificate pdf online

How to fill out and sign Dependent certificate pdf online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Finding a legal expert, creating an appointment and coming to the office for a personal meeting makes finishing a Dependent Certificate Form Pdf from beginning to end exhausting. US Legal Forms helps you to quickly make legally valid documents based on pre-built browser-based blanks.

Execute your docs within a few minutes using our straightforward step-by-step guide:

  1. Get the Dependent Certificate Form Pdf you want.
  2. Open it up using the cloud-based editor and start adjusting.
  3. Fill out the blank fields; involved parties names, addresses and numbers etc.
  4. Change the blanks with unique fillable fields.
  5. Include the day/time and place your electronic signature.
  6. Click on Done after twice-checking everything.
  7. Download the ready-produced papers to your system or print it out like a hard copy.

Easily generate a Dependent Certificate Form Pdf without having to involve professionals. We already have more than 3 million customers making the most of our rich collection of legal forms. Join us right now and gain access to the top library of browser-based templates. Test it yourself!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Certificate of eligibility form pdf FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to dependency in form

  • family dependent certificate format
  • parent dependent certificate format
  • dependent certificate form
  • dependent certificate by tehsildar in up
  • dependent certificate application
  • dependent certificate andhra pradesh
  • dependency certificate format pdf
  • dependency certificate for family pension
  • dental certificate sample
  • certificate of dependents
  • birth certificate of dependents sample
  • birth certificate of dependents in tagalog
  • ELIGIBILITY
  • inducement
  • enrollment
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.