Qualifying Life Event Request

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Employee or Member ID (Last 4 digits only)

Type of Qualifying Life Event

Date of Qualifying Event

Date

Please describe the qualifying event in detail

Are you requesting to add or remove dependents as a result of this event?

If adding or removing dependents, please list their names and relationship to you

Upload supporting documentation (e.g., marriage certificate, birth certificate, loss of coverage letter)

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Signature (Please sign to certify that the information provided is accurate)