Get Affidavit Of Extended Dependent Eligibility Age 26 30 Jhs

Completing the Affidavit of Extended Dependent Eligibility Age 26-30 JHS is a crucial step for employees wishing to extend their dependent coverage. This guide provides clear, step-by-step instructions to assist users in filling out the form accurately and efficiently online.

Follow the steps to complete the form for online submission.

1. Press the ‘Get Form’ button to access the Affidavit of Extended Dependent Eligibility Age 26-30 JHS and open it in a suitable editor.
2. Provide your personal information in the Employee Information section, including your name, AvMed Member ID number, address, city, state, zip code, contact phone number, and date of birth.
3. In the Dependent Information section, fill out the details for your dependent, including their last name, first name, date of birth, sex, and AvMed Member ID number.
4. Certify the eligibility of your dependent by checking all relevant boxes. Ensure you affirm that the dependent is unmarried, has no dependents, is a resident of Florida or a student, is without other insurance coverage, and has continuous coverage since turning 25.
5. If your dependent does not meet eligibility requirements, check the box under the Statement of Non-Eligible Dependent section, acknowledging that the dependent will be canceled retroactively.
6. Read and acknowledge the legal statement regarding the affidavit's binding nature. Ensure you understand the responsibility of notifying JHS and/or AvMed about any changes to your dependent’s status.
7. Attach supporting documentation as required, such as proof of Florida residency or school registration, and agree to provide additional documents if requested.
8. Sign the form, date it, and ensure you have a notary public witness your signature, providing their signature and commission expiration.
9. Once you have completed the form, save your changes, and prepare to download, print, or share the document as needed.

Start filling out your documents online today to ensure timely submission and processing.