Medical Plan

Marriage, divorce, legal separation or annulment.

Registration or termination of a domestic partnership.

Death of a child, spouse or Domestic Partner.

Birth, adoption or placement for adoption of a child.

The start or end of your spouse’s or Domestic Partner’s employment.

A change in your, your spouse’s or your Domestic Partner’s employment status.

Loss of status as a Dependent.

Loss of or change in your spouse’s or Domestic Partner’s health care coverage.

A court order which requires that a Dependent be covered under your medical coverage.

Please note, for any of the above provisions to apply to you and your Domestic Partner, your Domestic Partner must qualify as a Dependent under Internal Revenue Code Section 152.

Verification of relationship is required for any dependent being added for the first time to your coverage. Documentation may include a marriage certificate or domestic partnership statement to add a new spouse or domestic partner. Documents for a new dependent child may include a birth certificate or adoption papers, or other appropriate legal documents may be provided. Return a copy of the required documents to the Benefits Office within 31 days of the qualifying life event.

If you have a qualifying change in status, you must complete a change form within 31 days of the change. Any change in your elections must be consistent with the qualifying change in your circumstances.

Generally, the coverage due to a qualifying change in status starts on the first of the month following the receipt by the Benefits Office of the appropriate change form along with the Dependent Documentation. However, in case of birth or adoption of a child, the new coverage starts on the date of the event if the change form and Dependent Documentation were received within 31 days of the birth, adoption or placement for adoption.

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.