COVER SHEET To: Winston Benefits Fax: 1-732-903-1158 Attached: Dependent Verification Documents Employee Name: ______________________________________________ Employee ID: _____________ Contact phone: _____________________ Total number of pages including this cover sheet: _______ All previously unverified and newly added dependents covered by the medical, dental, and/or vision plans must be verified with supporting documentation. Please refer to the Required Documentation grid for complete documentation details. For each unverified or newly added dependent, you must fax or email this form along with the required supporting documentation to Winston Benefits. IMPORTANT: If you are faxing documentation you should retain a copy of the fax confirmation page for your records. Fax number: 1-732-903-1158 E-Mail Address: [email protected] Complete verification documentation must be received within 15 days of your timely completed enrollment or your unverified dependent(s) will not be covered and if applicable, your benefit coverage tier will automatically be reduced. Refer to the Required Documentation grid for complete documentation details. DEPENDENTS LAWFUL SPOUSE Your spouse as defined by the state law in which you were legally married, regardless of where you currently reside REQUIRED DOCUMENTATION The choice of option 1 or 2: 1. Copy of your state issued marriage certificate AND Copy of the first page of your current or previous year’s federal tax return that includes your spouse (you may conceal all financial information) OR Copy of your state issued marriage certificate AND Current dated (within last 90 days) proof of common residency such as a shared utility bill or bank statement with the common address indicated 2. The first and signature pages (or e-file confirmation page) of your current or previous year’s federal tax return showing marital status that includes your spouse (you may conceal all financial information) CHILDREN  Your dependent child up to the age of 26, including: o Natural born child o Legally adopted child (including children placed for the purpose of adoption) o Stepchild who resides in your home o Child related by blood or marriage for whom you or your lawful Spouse is the legal guardian o Child for whom you or your lawful Spouse are financially responsible for health care coverage under the terms of a Qualified Medical Child Support Order or other administrative order DEPENDENT CHILDREN WITH DISABILITIES Dependent children who are incapable of selfsustaining employment because of mental or physical disability, and became so prior to age 26, and is dependent on the employee for financial support and care Copy of the first and signature pages (or e-file confirmations page) of your current or previous year’s federal tax return that includes your child (you may conceal all financial information) OR  Natural Child – Copy of the child’s state issued birth certificate showing the employee’s name as parent.  Stepchild - Copy of the child’s state issued birth certificate showing the employee’s spouse’s name as a parent AND a copy of the marriage certificate showing the employee and parent’s name OR stepchild affidavit AND birth certificate showing the employee’s spouse’s name as parent.  Legal Guardian, Adoption or Foster Child – Copy of Affidavits of Dependency, Final Court Order with presiding judge’s signature and seal, or Adoption Final Decree with presiding judge’s signature and seal.  Documentation as noted for the “Child” dependent type AND  Notice of Award Letter from Social Security (SSI) of Supplemental Security Disability (SSDI) of child being found disabled. Please note that this documentation only verifies the child’s eligibility as a dependent, not the disability status of the child AND  Proof that the child resides with the employee. Updated 12/11/2013