Get Affidavit For Dependent Continuation Of Health Care Coverage ... - Franciscan

This guide provides clear instructions on completing the Affidavit for Dependent Continuation of Health Care Coverage under the Grandfathered Health Plan. By following these steps, you can ensure that your dependent receives the necessary health care coverage as mandated by the Affordable Care Act.

Follow the steps to complete the affidavit accurately.

1. Click ‘Get Form’ button to access the affidavit and open it in your preferred document editor.
2. Fill in your name in the designated space labeled 'Employee Name.' Ensure that the name matches your identification documents to avoid any discrepancies.
3. In the next field, enter the name of your dependent who will be covered under this health care coverage. Provide accurate and complete information.
4. Review and confirm that your dependent meets the eligibility requirements: they must be less than 26 years old, and not eligible for other employer-sponsored health plans.
5. Sign the document where indicated as 'Signature of Employee.' Ensure your signature is clear and follows your name.
6. Enter the date you are signing the affidavit in the specified area. This is important for keeping track of submission timelines.
7. The affidavit requires notarization. Ensure you take it to a notary public, who will witness your signature and provide their own signature and seal in the designated area.
8. If you are submitting for multiple dependents, ensure to complete a separate affidavit for each one.
9. Once the affidavit is complete, attach it to your enrollment form before submitting it to your employer for processing.

Complete your affidavit online now to secure health care coverage for your dependents.