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Employee Name:Emil ID:Department:Date of Birth: Open EnrollmentEffective January 1, 2015, New EnrollmentEffective Date: Change in Status/Coverage×Type of Change: Add Coverage Add Dependent Cancel
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Change in status coverage refers to a change in an individual's insurance policy or coverage.
Individuals who experience a qualifying life event that affects their insurance coverage are required to file a change in status coverage.
To fill out a change in status coverage, individuals typically need to complete a form provided by their insurance provider and provide documentation of the qualifying life event.
The purpose of change in status coverage is to ensure that individuals have the appropriate insurance coverage to reflect any changes in their life circumstances.
Information such as the qualifying life event, effective date of the change, and any additional documents supporting the change must be reported on a change in status coverage.
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