Get Qualified Status Change Form - Petsmart Benefits

The Qualified Status Change Form is essential for associates at PetSmart looking to make updates to their health benefits following a qualified status change event. This guide provides a clear and concise walkthrough of each section to ensure users can successfully complete the form online.

Follow the steps to fill out the Qualified Status Change Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information in the 'Associate Information' section. This includes your full name, daytime phone number, email address, associate number, location number, and last four digits of your social security number.
3. In the 'Qualified Status Change Event' section, select the event type that applies to you from the provided list. Then, provide the effective date of the change.
4. Gather and attach the required documentation based on the type of change you selected. Make sure you understand what is needed for your specific situation.
5. Proceed to the 'Health Plan Changes' section. Here, you can add or delete dependents by filling out their name, relationship, gender, date of birth, and their social security number, which is a required field.
6. If you are adding a spouse, confirm whether they have comparable coverage by checking the appropriate box. Be aware that a spousal surcharge may apply.
7. Review the cost associated with your chosen medical plan in the 'Medical/RX Weekly Cost' section. Ensure you understand how your changes impact your premiums.
8. Read and acknowledge the certification statement at the bottom of the form, ensuring you understand the implications of providing accurate information.
9. Finally, save any changes made to the form, and utilize the options to download, print, or share the document as necessary.

Complete your Qualified Status Change Form online to ensure your benefits are updated in a timely manner.