Get Request For Over-age Dependant Coverage Form - Human Resources - Spiritsd

This guide provides clear and user-friendly instructions for completing the Request For Over-Age Dependant Coverage Form. Whether you are requesting coverage for an over-age dependent or terminating existing coverage, these steps will help ensure your submission is accurate and complete.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to obtain the Request For Over-Age Dependant Coverage Form and open it in the editing tool.
2. Begin by filling out Section 1, which includes general information. Provide the plan sponsor name, plan number(s), plan member ID, your last and first name, middle initial, and your address, including city and postal code.
3. Complete the dependent's information, including their last and first name, address, city, and postal code.
4. If your dependent is disabled, complete Section 2 by attaching a report or letter from their physician confirming their diagnosis and prognosis, as well as their inability to work. Ensure that you provide the relationship to the plan member.
5. In Section 3, confirm if your dependent is a full-time student. You will need to provide details about the accredited institution they are enrolled in, including the name, location, date the school year begins and ends.
6. For termination purposes, if applicable, fill out Section 4 by indicating the effective date of termination and the reason. Include the dependent's name for whom you wish to terminate coverage.
7. Finally, sign the form in Section 5 to certify that all information is accurate. Include the date signed.
8. Once you have completed the form, review all entries for accuracy and clarity. After confirming the form is filled out correctly, you can save changes, download a copy, print it, or share the form as needed.

Now that you have the instructions, complete your Request For Over-Age Dependant Coverage Form online.