Insurance Change Form for Plan Year 2024

Midyear changes – To be eligible to add, drop or change coverage on yourself and/or your dependents after your initial enrollment (other than Option Period), you must experience a midyear qualifying event. You must make your elections and sign this form within 30 days of the qualifying event.
Strict rules apply to all qualifying events. Benefit changes must be consistent with the qualifying event. Changes must also be necessary or appropriate as a result of the qualifying event; e.g., adding health coverage (a benefit election change) is not consistent with the loss of a dependent (qualifying event). Allowable midyear changes within plan guidelines include:

• Change in your legal marital status.
• Change in your number of dependents.
• Change in your or your dependent’s employment status that directly affects eligibility. • An event that causes your dependent to satisfy, or cease to satisfy, eligibility requirements (age 26, etc.).
• Changes in your or your dependent’s place of residence that directly effects eligibility or HMO/DMO availability.
• Beginning or returning from FMLA leave, leave without pay, USERRA leave or disability leave. Changes that do not fall into the above categories are generally not allowed except during Option Period. If you have questions regarding a midyear qualifying event, please contact your insurance coordinator.

If you declined member or dependent life coverage because you had group life coverage through a source other than your participating employer and later lose that coverage, you can request coverage (up to the amount lost, rounded up to the next $20,000 unit) under the Plan within 30 days of loss of the other group life coverage. Your request must be accompanied by proof of loss of the other group life coverage that indicates the date of loss and the amount of coverage. A life insurance application is not required if coverage is requested within this 30-day period. To be eligible to add Dependent Life and enroll your dependents as a midyear qualifying event, you must first be enrolled in or qualify to add at least Basic Life at that time.
To be eligible to add dental and/or life coverage through EGID, you must first be enrolled in or qualify to add health coverage at that time. You can exclude health coverage if you have other verifiable health coverage. You may be asked to provide proof of that coverage. Failure to provide proof upon request will result in termination of all coverage.

Dependent coverage – Dependent children must be under 26 to be eligible for enrollment.
Your dependents are not eligible for any coverage in which you are not enrolled. If you cover one eligible dependent, you must cover all your eligible dependents. You can elect not to cover dependents who do not reside with you, are married, are not financially dependent on you for support, have other qualified health coverage, or are eligible for Indian or military benefits. You may be asked to provide proof of that coverage. Failure to provide proof when requested will result in termination of coverage for your dependents.
You can cover your children and exclude your spouse from health, dental and/or vision coverage. If you choose this option, your spouse must sign and date the Spouse Exclusion Certification section of this form.
You can cover your children and exclude your spouse from Dependent Life coverage only if your spouse has other qualified life coverage. You may be asked to provide proof of that coverage. Failure to provide proof when requested will result in termination of all coverage.
Once publicly declared, a common-law relationship can be dissolved only by legal divorce.

Notification time limits – The deadline for submitting this form to EGID is strictly enforced. Forms not received within the specified time will not be processed. Your form must be received by EGID within 40 days of the qualifying event.

Confirmation statement − When you make changes to your coverage, EGID sends you a confirmation statement that lists the coverage you are enrolled in, the effective date of your coverage and the premium amounts. It allows you to review your coverage so that any errors can be identified and corrected. Corrections must be submitted to your insurance coordinator or EGID within 60 days of the election. Corrections reported after 60 days are effective the first of the month following notification.