Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 448 According to the Internal Revenue Service (IRS) regulations that govern flexible benefit plans, the optional Benefits you elect during enrollment must remain in effect throughout the calendar year, unless you experience a qualified change of life event. If you decide to change your elections as the result of one of the events listed below, you must do so within 30 days after the qualifying event. If you do NOT notify the Human Resources Office within 30 days after the event, you cannot change your elections until the next annual open enrollment. You must provide the Human Resources Office with veri- fication of all change of life events. Change of Life Events Event Qualified Status Change How to begin If you experience a life change – such as marriage, legal separation, divorce, birth or adoption of a child, or death. If you, your spouse or dependent child become covered by another plan or lose coverage in another plan. If you experience a loss of coverage due to relocation out of the Plan’s coverage area. If your physician or facility discontinues participation in plan. Yes – you have 30 days to notify Human Resources. Yes – you have 30 days to notify Human Resources. Yes – you have 30 days to notify Human Resources. No you must wait until the next open enrollment to change plans. •  Log into One-Source and make a request to add or drop/delete dependents. •  Provide HR with certified docu- mentation such as a marriage license, birth certificate, divorce decree or other legal document. •  Log into One-Source and make a request to enroll (or disenroll) in our benefits or to add dependents to your existing plan. •  Provide HR with proof of previous (or new) coverage from the family members insurance carrier and/or former employer. •  Log into One-Source and make a request to enroll in another health and/or dental plan. •  Provide HR with proof of your new residence. •  You must wait until the next open enrollment to change plans.