Health Care Eligibility Change Form

Health Care Plan Eligibility Form

Use this form only if your child who is over the age of 26 is (a) married, (b) no longer a full-time student, or (c) no longer qualifies as a disabled individual under the health plan.

Other health plan changes should be made through UBenefits at ubenefits.app.utah.edu

Name

First

Last

Employee ID#

Today's Date

Email Address

Work Phone

Home/Cell Phone

Child's Name

First

Last

Reason Child No Longer Qualifies

Marriage

Not a Full-Time Student

No Longer Qualifies as Disabled Individual

Date of Marriage

Date Student Last Attended Classes or Graduated

Date Child No Longer Meets Definition

I hereby request that the University change my enrollment in the Employee Health Care Plan, hereinafter known as the Plan, as noted hereon, subject to prevailing rules of the Plan. I hereby acknowledge and certify the following: (please check each box to acknowledge)

All information provided on this form is true and correct.

My child’s eligibility for coverage ends at 12:00 am on the date stated above. I will be required to reimburse the health plan for any claims paid after my child’s eligibility ends.

My premium payments will not be adjusted (if my coverage changes from family to two-party or from two-party to single coverage) until a change form is submitted. There will be no refund for premiums paid between coverage end date and change form submission.

I must notify the University Human Resource Management within 60 days of the date my dependent loses eligibility for coverage in order for them to be eligible for COBRA Continuation Coverage

Any person who knowingly files an enrollment form containing any misrepresentation or any false, incomplete, or misleading information may be subject to discipline up to and including termination of employment and cancellation of coverage, and may be guilty of a criminal act punishable under law and subject to civil penalties

If you are human, leave this field blank.