Benefeds Belated Enrollment – Fill Out and Use This PDF

Federal Employees Dental and Vision Insurance Program (FEDVIP)

Belated Enrollment/Change Form

Use this form only to request approval for a belated FEDVIP enrollment, change to an existing FEDVIP enrollment, or cancellation of your FEDVIP enrollment.

We will consider your request if you were unable to perform, due to specific reasons beyond your control, the requested action during the Federal Benefits Open Season or within 60 days of a qualifying life event (QLE) or becoming a new

or newly eligible employee. (Examples of a QLE may be a change in family status that results in the increase or decrease in the number of eligible family members or an employee being restored to civilian status after serving in the uniformed services.) BENEFEDS must receive your completed form within three months of the last day of the Federal Benefits Open Season, your QLE date, or your new hire or newly eligible date. Incomplete forms will not be processed.

Section A: Contact Information

Provide as much accurate information as possible. We cannot process your request if we cannot reach you.

2.If this is NOT a Federal Benefits Open Season request and involves a QLE or a new hire or newly eligible request, please enter your QLE, new hire, or newly eligible date.

Date of QLE, new hire, or new eligibility

(mm/dd/yyyy)

3. Is this request for a FEDVIP dental plan and/or a FEDVIP vision plan?

CONTINUE ON REVERSE

4. Below are the valid reasons for which approval of this request will be considered.

uYou had no access to a telephone or the Internet for the entire duration of the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.

uYou had a significant medical emergency for yourself or an immediate family member and you were unable to perform your requested action for a significant portion of the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.

uA member of your immediate family passed away and you were unable to perform your requested action during the Federal Benefits Open Season or within 60 days of a QLE or becoming a new or newly eligible employee.

Please explain why you could not enroll, make a change, or cancel your enrollment during the eligible time frame.

We will base our decision on the information you provide, so please be as detailed as possible. While we review this information, we may request additional documentation to support your reason.

Please note: We will send you a written notice of our decision. If your request is approved, the following points apply.

uYou will have 30 days from the date on your approval letter to contact BENEFEDS to execute your request.

uPer Federal law, a belated enrollment, change, or cancellation must be retroactive to the effective date it would originally have been, had the request for the change been received within the eligible time frame.

uIf the change results in past due premiums, Federal law states that these premiums must be paid by direct bill. Failure to make this direct bill payment will result in a termination of your enrollment.

Section C: Signature and Mailing / Fax Instructions

Print name

(Required)

Signature

(Required)

Date signed//

(Required: mm/dd/yyyy)

BEN09007 1112