Get the free Authorize Elections and Dependent Eligibility Certification Form - rochester

This document is used to authorize elections regarding health care and dental plans, certify dependent eligibility, and provide information on premium deductions from salary.

How to fill out authorize elections and dependent

How to fill out Authorize Elections and Dependent Eligibility Certification Form

1. Obtain the Authorize Elections and Dependent Eligibility Certification Form from your HR department or company website.
2. Carefully read the instructions provided on the form to ensure you understand what is required.
3. Fill out your personal information such as name, employee identification number, and contact details.
4. Indicate the elections you wish to authorize by checking the appropriate boxes.
5. Provide information about your dependents including their names, birthdates, and relationship to you.
6. Sign and date the form to certify that all information is accurate and complete.
7. Submit the completed form to your HR department by the specified deadline.

Who needs Authorize Elections and Dependent Eligibility Certification Form?

1. Employees who want to enroll in or change their benefits offerings.
2. Employees with dependents that need to be added or verified for eligibility in benefit programs.

For pdfFiller’s FAQs

What is Authorize Elections and Dependent Eligibility Certification Form?

The Authorize Elections and Dependent Eligibility Certification Form is a document used to certify an employee's eligibility for benefits and to authorize elections regarding benefits enrollment.

Who is required to file Authorize Elections and Dependent Eligibility Certification Form?

Employees who wish to enroll in benefits plans or make changes to their dependent coverage must file the Authorize Elections and Dependent Eligibility Certification Form.

How to fill out Authorize Elections and Dependent Eligibility Certification Form?

To fill out the form, provide personal information such as name and employee ID, select the benefits elections you wish to authorize, and list any eligible dependents requiring coverage.

What is the purpose of Authorize Elections and Dependent Eligibility Certification Form?

The purpose of the form is to ensure that employees are correctly enrolled in benefits plans and that all dependents listed meet the eligibility criteria.

What information must be reported on Authorize Elections and Dependent Eligibility Certification Form?

The form must report the employee's identification details, selected benefits options, and information about all dependents, including their names, dates of birth, and relationship to the employee.