Form Ers Gi 1 180 – Fill Out and Use This PDF

SSn _______________________________________ employee name: First, mi, last _________________________________________________

SECTION E: DEPENDENT PERSONAL DATA (And coverage choices.)

	Dependent	Dependent’s Name		Date of	Dependent SSN	Health	Dental	Dep. Life
			Gender	Birth
	Relationship*	(First,MI,Last)			(Required for 12 months or older)
				(mm-dd-yyyy)
	o Sp o D		o M			oYes	oYes	oYes
	o S o O		o F			o No	o No	o No
	o Sp o D		o M			oYes	oYes	oYes
	o S o O		o F			o No	o No	o No
	o Sp o D		o M			oYes	oYes	oYes
	o S o O		o F			o No	o No	o No
	o Sp o D		o M			oYes	oYes	oYes
	o S o O		o F			o No	o No	o No
	o Sp o D		o M			oYes	oYes	oYes
	o S o O		o F			o No	o No	o No

*Relationship Code: Sp – Spouse D or S - Natural or adopted daughter or son O – Other than natural or adopted child. Includes stepchild, foster child, or ward child. If you are adding a child, you must complete a Dependent Child Certiication form (ERS GI 1.081) available at www.ers.state.tx.us or by calling ERS.

Did your dependent have GBP coverage under ERS through another member within the last 31 days? o Yes o No

If yes, please provide the Social Security number under which your dependent was covered: _________________________________

Is this dependent a new addition to your household because of this event?

Please check one only: oAdoption

oBirth

oMarriage

oAcquisition of other than natural child

oNot newly acquired

Section F: AuthoRizAtion (Carefully read the statements below before you sign and date.)

I authorize payroll deductions for the elections indicated on this Beneits Election Form. I understand that my insurance coverage may be cancelled if I do not pay the required amounts due, either by payroll deduction or personal payment. I understand that all insurance premiums are deducted on a pre-tax basis, except Dependent Life and Disability. I authorize any provider to release any information on persons covered when needed to verify eligibility or to process an insurance claim/complaint. I understand that insurance participation rules and enrollment and beneits information are available from my beneits coordinator/accessHR or ERS. I understand that double coverage for dependents is not allowed for health and dental coverage in theTexas Employees Group Beneits Program (GBP).

I understand that state law does not permit me to receive more than one state insurance contribution as either an employee, retiree, or dependent. I understand that acceptance of a premium does not constitute valid enrollment of the ineligible person nor waive the eligibility requirements for coverage. I understand that my GBP coverage will remain in effect for the plan year unless I have a qualifying life event (QLE) and that a QLE does not always allow me to make changes to my insurance coverage because the insurance change must be allowable under the GBP rules, AND be consistent with the QLE. notice about insurance - Funding for health and other insurance beneits for participants in the Texas Employees Group Beneits Program (GBP) is subject to change based on available State funding.The Texas Legislature determines the level of funding for such beneits and has no continuing obligation to provide funding for those beneits beyond each iscal year. I understand I may be asked to show documentation to support my selection. False information could lead to expulsion from the GBP and/or criminal prosecution. I certify that all information provided on this form is valid and true to the best of my knowledge.

Employee’s Signature _________________________________________________Date Signed (mm-dd-yyyy) _____________

Keep a copy of this form for your iles and return the original to your beneits coordinator.

If you are a Health and Human Services Enterprise employee, return this form to accessHR

ERS GI-1.180 (R 09/2011) (Page 2 of 4)

Family Status Change Reference Chart

	Employee Marital	Participant gets married	MAR
		Participant gets a divorce or an annulment	DIV
	Status Change
		Death of a spouse	DOD
		Birth of a newborn child	BIR
		Participant adopts, fosters, or gets court-appointed guardianship of child	ADP
		Participant gains or loses dependent(s) through death	DOD
	Dependent	Dependent becomes eligible or loses eligibility for insurance coverage
		(Example: Participant’s spouse is covering their child.The child lost eligibility for	DEP
	Status Change
		the spouse’s insurance because the child does not attend school.)
		Dependent is related by blood or marriage, and was previously claimed on the participant’s in-	XMO
		come tax return, but is no longer eligible to be claimed on participants income tax return
		Child gets married	DGM
	Employment	Participant/Dependent employment status change	ESC
	Status Change	Dependent becomes eligible for insurance after a waiting period	DWP
	Address Change that Changes	Dependent moves out of health or dental plan service area	DMV
	Dependent Eligibility
	Medicare/	Participant/Dependent gains Medicare/Medicaid/CHIP eligibility	MDG
	Medicaid/CHIP
		Participant/Dependent loses Medicare/Medicaid/CHIP eligibility	MDL
	Eligibility Change
	Signiicant Change	Signiicant change in cost by day care provider	SCC
	in Cost/Coverage
		Signiicant change in cost/coverage of dependent’s health or dental plan (excluding GBP)	SCC
	Imposed by
		HIPP approval or loss of eligibility	SCC
	Third Party
	Court Ordered	Participant gains requirement to provide coverage for child/spouse	MSO
		(Example: employee receives a medical support order to provide health coverage for his child.)
	Coverage Change
		Participant requirement to provide coverage for child/spouse expires
	(Eligibility rules apply for
		(Example: employee’s medical support order to provide health coverage for his child expires and	MSD*
	these dependents)
		the employee is no longer required to continue coverage for the child.)

*Employees must contact their beneits coordinator (HHS Enterprise employees contact accessHR) to drop dependent(s) added with an MSO.

Beneit changes must be consistent with the QLE. Dependent eligibility and enrollment rules apply.

You may either enter your changes using your online account at www.ers.state.tx.us or send this form to your beneits coordinator. If you are a Health and Human Services Enterprise employee, you may send this form to accessHR.

You may be asked to show proof of the QLE or proof of dependent eligibility.

ERS GI-1.180 (R 09/2011) (Page 3 of 4)

ERS GI-1.180 (R 09/2011) (Page 4 of 4)