Caroline County Qualifying Event Change Form

You may add or drop health or dental coverage for you or your dependents, outside of the annual open enrollment period, only if one of the following “qualifying events” occurs:

Marriage of the employee (coverage effective month after marriage date)
         Date of Marriage

Divorce or Legal Separation of employee (Court papers should be provided)
         Date of Divorce or Legal Separation
(Please indicate address of ex-spouse)



Birth of a child.
         Date of Child’s Birth

Adoption of a child by the employee (Court papers should be provided)
         Date of Adoption

Obtaining custody of a child. (Court papers should be provided)
         Date of Custody

Death of the employee's spouse or dependent.

         Date of Death

Change of employment status of the employee or employee's spouse

An unpaid leave of absence by the employee or spouse.

Significant change in spouse's employer-provided insurance coverage.

Dependent child no longer eligible for coverage. (Please indicate address for child if different from employee)

For added coverage, please choose effective date of change:
         1st day of next month
         1st day of the following month For dropped coverage, changes are effective the last day of the month of your life event.
         Other:

According to the IRS federal code (Section 125, pretax option), benefit changes must be consistent with your qualifying event. Qualifying event benefit changes must be made within 31 days of the event. Changes made by the County of Caroline and its employees are subject to review for compliance.

Employee Name: SS#:
Employee Signature: Date:

Please send this completed form along with your benefit enrollment/change forms to Lesley Moore, Human Resource Manager, Caroline County