Qualifying Life Event Form

ATTENTION: HR must receive this Qualifying Life Event (QLE) form within 31 days* of the event. Employees are encouraged to report QLEs prior to the 31 days for the earliest possible effective date.


Changes will be effective the first day of the month following submission of this form. (Exceptions: births & adoptions will be effective the date of event).


Submit Completed Form AND Supporting Documentation to HR Benefits (see below for supporting documentation requirements).


*You have 31 days to notify HR Benefits, unless you are entitled to additional time under federal policy or program.



Click here to access the Benefits Guide

Please review the benefit plan information and bi-weekly premiums BEFORE making your selection(s).


Questions? Contact HR Benefits at benefits@hendrickhealth.org or call 325-670-3163

If yes, please add your Address, City, State, and Zip in the comment box. If no change is needed, please skip.

Please indicate your qualifying life event reason for your election change request(s). See bottom of form for required documentation for each type of event.

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If you are removing a spouse from your insurance coverage(s) due to divorce, please list their new address in the comment box (if known). If this does not apply, please skip.

Please indicate the date your qualifying life event took place. (Example: Marriage - If you got married on June 15, 2023, your QLE date would be 06/15/2023.)

Pre-Tax Plans

**Indicate changes only**

If electing new coverage, please select one Plan Election. If revising existing coverage, Plan Election will remain the same. If you would like to cancel, select Cancel Coverage. If no change is requested, please skip.

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If electing new coverage, please make your selection below indicating tobacco status. For information about the tobacco surcharge, including reasonable alternatives, refer to the Benefits Guide. Default option if this step is skipped – Tobacco User.

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Please make your selection. Premiums are based on Salary Range, Wellness Discount(s) and Tobacco Status - refer to the Benefits Guide. If no change is requested, please skip.

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Please make your selection. If revising existing coverage, Plan Election will remain the same. If no change is requested, please skip. Refer to the Benefits Guide for bi-weekly premiums.

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Please make your selection. If no change is requested, please skip.

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Please make your selection. If no change is requested, please skip. Refer to the Benefits Guide for bi-weekly premiums.

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Please make your selection. If no change is requested, please skip

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The 2025 Maximum Annual Contribution is $3,300. Contributions not used within the plan year will be forfeited excluding a $660 rollover. If no change is requested, please skip.

The 2025 Maximum Annual Contribution is $5,000 per household ($2,500 if married, filing separately). Contributions not used within the plan year will be forfeited - there is not a rollover for DCFSA. If no change is requested, please skip.

The 2025 Maximum Annual Contribution is $4,300 (single)/$8,550 (family) (+$1,000 if age 55+). Contributions not used within the plan year will rollover year to year. If no change is requested, please skip.

After-Tax Plans

**Indicate changes only**

Please make your selection. If no change is requested, please skip.

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New Election? If yes, indicate smoker status and coverage amount desired. If no change is requested, please skip.

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Amount must be in $5,000 increments; maximum coverage amount = lesser of $500,000 or 100% of Employee’s Optional Life Benefit. (GI Limit = $25,000; EOI required for amount exceeding GI Limit - refer to the Benefits Guide for more information). If no change is requested, please skip.

Please make your selection. If no change is requested, please skip.

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Please make your selection. If no change is requested, please skip.

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Please make your selection. If no change is requested, please skip.

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Please make your selection. If no change is requested, please skip.

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Please make your selection. (Dependent children are automatically covered at 25% of Employees policy amount free of charge, if employee is currently enrolled). If no change is requested, please skip.

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Please make your selection. If no change is requested, please skip.

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Spouse coverage amounts = $5,000, $10,000, or $15,000 not to exceed 100% of Employee’s Critical Illness coverage. If no change is requested, please skip.

Please make your selection. If no change is requested, please skip.

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Please make your selection. If revising existing coverage, Plan Election (Benefit Premeir or Benefit Essential) will remain the same. If no change is requested, please skip.

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Please make your selection. If no change is requested, please skip.

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Newly Enrolled Dependent Information

If you are requesting new dependent(s) be added to your insurance coverage(s), please complete this section. If this does not apply, please skip.

Please list the first dependent in the comment box and include all of the following: First, MI, Last Name, SSN, DOB, Gender, and Relation (spouse or child).

Please select all that apply.

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Please list the first dependent in the comment box and include all of the following: First, MI, Last Name, SSN, DOB, Gender, and Relation (spouse or child).

Please select all that apply.

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Please list the first dependent in the comment box and include all of the following: First, MI, Last Name, SSN, DOB, Gender, and Relation (spouse or child).

Please select all that apply.

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Please list the first dependent in the comment box and include all of the following: First, MI, Last Name, SSN, DOB, Gender, and Relation (spouse or child).

Please select all that apply.

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If any of your Newly Enrolled Dependents are disabled please list their First and Last Name in the comment box. If this does not apply, please skip.

Removing Dependent(s)

If you are requesting dependent(s) be removed from your insurance coverage(s), please complete this section. If this does not apply, please skip.

Please list dependents to be removed in the comment box and include the following: first and last name and coverage(s) removed (medical, dental, vision, and/or other). If multiple dependents, separate with a semicolon ";" If this does not apply, please skip.

Employee Authorization

I have received, read, and understand benefit notices; including, but not limited to: the Summary of Benefits and Coverage (SBC), Medicare Part D Credible Coverage, Plan Document(s), and the Cafeteria Plan Document explaining the health plan. I understand all benefit notices are housed on the Human Resources Benefits page on the Hendrick Hub (paper copies provided upon request). I understand that by signing and submitting this form, I am making an election concerning my benefits for the enrollment period through December 31, 2024. This election is binding subject to my right to make changes according to provisions of the program and subject to any changes required to comply with federal tax laws.


By signing this form, I authorize Hendrick to inform appropriate insurance carriers of my election enrollment(s) and/or change(s). I verify that the information on this form is true and correct.


My electronic signature is the same as my written signature.

Type your first and last name as your electronic signature.

If required documentation is missing, your QLE Form will not be processed until it has been received by HR Benefits, provided the documentation is submitted timely. If you are not able to submit documentation with the submission of this form, please continue with the submission and provide supporting documentation timely by visiting the benefits website at Hendrick.Health/employeebenefits and click on Submit Forms.


QUALIFYING LIFE EVENT VERIFICATION DOCUMENTS

Event Type: Document(s) Required

Marriage**: Marriage Certificate

Birth*: Birth Certificate(s)

Adoption: Signed Court Paperwork

Gain of Coverage: Document showing gain of coverage (must show name(s), effective date, a coverage type gained)

Loss of Coverage*: Document showing loss of coverage (must show name(s), effective date, and coverage type lost)

Divorce (removing newly ineligible dependents)**: Signed Divorce Decree

Death**: Death Certificate


*Additional documents are required to verify dependent eligibility, if covering spouse and/or child(ren)

**Information regarding beneficiary changes can be found on the Human Resources page of the Hendrick Hub.


DEPENDENT VERIFICATION DOCUMENTS

Dependent Type: Dependent Eligibility Document(s) Required

Legal Spouse: Government issued marriage certificate AND one of the following if you have been married longer than 12 months:

-Federal tax return issued within last 2 years (Must show the filing year, both names, last 4 of both SSNs, and signatures. You may mark out all other information.)

-Proof of joint ownership issued within last 6 months.

Informal or Common-Law Spouse: Notarized affidavit of common law marriage or Declaration of Informal Marriage AND one of the following:

-Federal tax return issued within last 2 years (Must show the filing year, both names, last 4 of both SSNs, and signatures. You may mark out all other information.)

-Proof of joint ownership issued within last 6 months

Biological Child: Birth Certificate

Stepchild: Birth Certificate and spouse eligibility document(s) – see above

Adopted or Foster Child: Signed Court Paperwork

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Confirmation

We highly recommend checking the box "Send me a copy of my responses" as confirmation your submission was successful.

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