Examples Life Event Documentation

Change in Family Status

Natural Child
▪ Birth certificate, or hospital birth record indicating the employee is the child’s parent, or
▪ Passport indicating the employee is the child’s parent, or
▪ Court order establishing the employee’s financial responsibility for the child’s medical, dental, or other health care, or
▪ Copy of public aid order indicating the employee must provide health insurance through the employer.

Adoption
▪ Adoption decree/order with judge’s signature and circuit clerk’s file stamp, or
▪ Petition for adoption with circuit clerk’s file stamp, or
▪ Letter of placement by an adoption agency.
▪ Legal Guardianship
▪ Court document signed by judge and stamped by the circuit clerk showing legal guardianship

Legal Guardianship
▪ Court document signed by judge and stamped by the circuit clerk showing legal guardianship

Disabled Dependent
▪ Documentation from a licensed physician detailing the dependent's disability and that the disability existed before age 19, and a statement from the Social Security Administration with the Social Security disability determination or a court order adjudicating the disability.

Death of your spouse/domestic partner/common-law spouse or dependent child
▪ Death Certificate, or
▪ Certified copy of the public record of death, or
▪ Certified copy of a coroner’s certificate
▪ Divorce/Dissolution of Partnership
▪ Divorce or separation decree, or
▪ Legal separation agreement, or
▪ Dissolution of Domestic Partnership form
▪ Marriage/ domestic partnership/common-law spouse
▪ Marriage license/certificate, or
▪ Notarized copy of a public record showing date of marriage, or
▪ Declaration of Same-Sex Domestic Partnership for Enrollment or Eligibility, or
▪ Affidavit of Domestic Partnership, or
▪ Registration of Domestic Partnership, or
▪ Affidavit of Dependency for Tax Purposes, or
▪ Affidavit of Common Law Marriage

Divorce/Dissolution of Partnership
▪ Divorce or separation decree, or
▪ Legal separation agreement, or
▪ Dissolution of Domestic Partnership form

Marriage/ domestic partnership/common-law spouse
▪ Marriage license/certificate, or
▪ Notarized copy of a public record showing date of marriage, or
▪ Declaration of Same-Sex Domestic Partnership for Enrollment or Eligibility, or
▪ Affidavit of Domestic Partnership, or
▪ Registration of Domestic Partnership, or
▪ Affidavit of Dependency for Tax Purposes, or
▪ Affidavit of Common Law Marriage

Change in Coverage

When adding or terminating benefit coverage for family members, supporting documentation must be provided along with documentation of the qualifying life event.

Proof of Union
▪ Marriage license/certificate, or
▪ Notarized copy of public record, or
▪ Declaration of Same-sex Domestic Partnership for Enrollment or Eligibility, or
▪ Affidavit of Domestic Partnership, or
▪ Registration of Domestic Partnership, or
▪ Affidavit of Dependency for Tax Purposes, or
▪ Birth certificate
▪ AND
▪ Spouse coverage status change (enrollment or termination notice, etc.), or
▪ Spouse employment status documents (offer letter, COBRA notice, etc.), or
▪ Letter from other employer documenting loss or gain of coverage and date, or
▪ Court/Administrative Orders to initiate or end coverage, or
▪ Letter from insurance provider where coverage was lost or gained (i.e. Iowa Health plan, hawk-i, other country),
▪ If dependent is moving from outside the U.S. to live within the U.S. and you are adding them to your coverage, you must also provide evidence of the event such as a copy of Visa or Passport showing
entry into U.S.

Change of Residence
▪ Change of residency for your spouse/domestic partner/common-law
spouse or dependent child
▪ Voter registration card, or
▪ Vehicle registration certificate, or
▪ Rental or lease agreement showing 30 days of residency

If you have additional questions about your benefits, please Submit a Ticket.