Dependent Type

Definition

Required Documentation

Spouse

The covered employee’s spouse according to the laws of the state where the employee lives or was married.

OPTION 1

• Copy of most recent federal tax return showing spouse (Front and signature pages only)

OPTION 2

• Marriage certificate; AND
• Proof of joint ownership dated within the past 60 days (e.g. joint bank statement, credit card, mortgage, etc.)

Social Security numbers and financial information can be marked out

Domestic Partner

The covered employee’s domestic partner in accordance to the laws of the state where the employee lives for domestic partner relationships

The Employee and the individual must have a signed and notarized Affidavit of Domestic Partnership
 and at least two of the following items:
 • A joint mortgage or lease agreement;
 • A notarized mutual assignment of Power of Attorney for financial and medical purposes;
 • A joint checking or credit account;
 • A formal commitment ceremony document, which is subject to validation;
 • A primary beneficiary designation for will, life insurance and/or retirement benefits.

A child(ren) of the domestic partner is not eligible for benefit coverage unless there is a legal adoption in place.

Dependent Child under age 26

Natural-born children or legally adopted children, whether or not such children live with the employee

NATURAL-BORN CHILD:

• Birth certificate

ADOPTED CHILD:

• Amended birth certificate naming employee as parent; OR
• Copy of adoption papers

Step-Children under age 26

Children whose natural parent is married to and resides with the team member

• Birth certificate; AND
• Proof of marriage to a natural parent (see required documents for Spouse above)

Disabled Child over age 26

A covered child who reaches the limiting age (26 years old) and is totally disabled, incapable of self-sustaining employment by reason of mental or physical handicap, primarily dependent upon the covered employee for support and maintenance and unmarried. The plan administrator may require, at reasonable intervals during the two years following the dependent’s reaching the limiting age, subsequent proof of the child’s total disability and dependency.

• Birth certificate; AND
• Physician letter with a statement of Total and Permanent Disability, completed and signed by the dependent’s physician (stamped signature not acceptable); AND
• Copy of current federal tax return (front and signature pages only); AND
• Copy of Supplemental Security Income (SSI) award, if eligible.

Qualified Medical Child Support

Any child of a plan participant who is an alternate recipient under a qualified medical child support order shall be considered as having a right to dependent coverage under this plan

• Final court order with presiding judge’s signature; OR
• Qualified Medical Child Support Order (QMCSO) showing date of birth