Integrity | Qualifying Life Event

Please note that you only have 30 days from the date of the qualifying event or family status changes to provide documentation. The information below will be used to verify your identify before any changes are made to your employee record.

Company Name*

Employee Name*

First NameMiddle NameLast Name

Employee Email Address*

example@example.com

Employee Number or Last Four of Social Security Number (SSN)*

What Qualifying Event Occurred?*

Change in Legal Martial Status Type*

Required Document(s)*

Marriage - Marriage certificate
Divorce/Annulment - Divorce decree/Court ruling for annulment
Legal Separation - Court order verifying legal separation
Death of Spouse - Death certificate

Change in Number of Dependents Type*

Required Document(s)*

Birth - Birth certificate
Death - Death certificate
Change of custody, judgement, court order or decree requiring health coverage - Court documentation, including qualified medical child support order (QMSCO)
Adoption/Placement for Adoption - Court order for adoption/placement for adoption

Gain or Loss in Eligibility Coverage Type*

Required Document(s)*

Group Health Plan - Documentation from plan or issuer regarding change in eligibility
Loss of Coverage - Termination of coverage document with effective date
Gain in Coverage - Benefit confirmation document with effective date
Change in Worksite - Employer documentation showing change and impact on eligibility

Change in place of residence of the employee, spouse or dependent that affects HMO eligibility

Required Document(s)*
Documents indicating how change in residence affects employee eligibility

Employee, spouse or dependent becomes covered under Medicare or Medicaid, or lose eligibility of their benefits or Medicaid coverage (including coverage under a state Children's Healthcare Insurance Program or CHIP)

Required Document(s)*
Government verification that coverage was gained or lost

Supporting Documentation*