2023 T&M Associates Qualifying Life Event Enrollment Form

Employee Name*

First NameMiddle InitialLast Name

Please select the reason for your change*

Please upload a document that shows a proof of coverage or loss (marriage certificate, birth certificate, loss of coverage form). Proof of the life event must be submitted within 30 days of the effective date.

Browse Files

Date of Qualifying Life Event*

This is the date that your event occurred.

Wellness Program

Please check this box if you've completed the previous year's wellness program

All contribution rates are per pay period*

IMPORTANT: The cancellation of Medical Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.

If you are covered under another insurance plan, please provide a copy of your other medical ID card to Human Resources.

If you wish to contribute to your HSA, please select:

HSA Per Pay Contribution

HSA Annual Contribution

Please select Healthcare FSA, Dependent Care FSA, or Both

Enrolling in the Healthcare FSA (26 pays per year)

Enrolling in the Dependent Care FSA (26 pays per year)

All contribution rates are per pay period*

IMPORTANT: The cancellation of Dental Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.

All contribution rates are per pay period*

IMPORTANT: The cancellation of Vision Insurance will waive coverage until the next Open Enrollment period unless a Qualifying Life Event takes place.

Spouse Information

Click here if you will be adding a spouse to your healthcare plan.

Spouse's Name*

First NameMiddle InitialLast Name

Spouse's Gender*

Spouse's Date of Birth*

Spouse's Social Security Number*

Enroll Spouse in (check all that apply)*

MedicalDentalVision

Child/Children Information

Click here if you will be adding a child/children to your healthcare plan.

Please select the number of children who will be enrolled.

(1) Child's Name*

First NameMiddle InitialLast Name

(1) Child's Gender*

(1) Child's Date of Birth*

(1) Child's Social Security Number*

(1) Enroll Child in (check all that apply)*

MedicalDentalVision

(2) Child's Name*

First NameMiddle InitialLast Name

(2) Child's Gender*

(2) Child's Date of Birth*

(2) Child's Social Security Number*

(2) Enroll Child in (check all that apply)*

MedicalDentalVision

(3) Child's Name*

First NameMiddle InitialLast Name

(3) Child's Gender*

(3) Child's Date of Birth*

(3) Child's Social Security Number*

(3) Enroll Child in (check all that apply)*

MedicalDentalVision

(4) Child's Name*

First NameMiddle InitialLast Name

(4) Child's Gender*

(4) Child's Date of Birth*

(4) Child's Social Security Number*

(4) Enroll Child in (check all that apply)*

MedicalDentalVision

(5) Child's Name*

First NameMiddle InitialLast Name

(5) Child's Gender*

(5) Child's Date of Birth*

(5) Child's Social Security Number*

(5) Enroll Child in (check all that apply)*

MedicalDentalVision

(6) Child's Name*

First NameMiddle InitialLast Name

(6) Child's Gender*

(6) Child's Date of Birth*

(6) Child's Social Security Number*

(6) Enroll Child in (check all that apply)*

MedicalDentalVision

BENEFICIARY INFORMATION

If you would like to change your beneficiaries for life insurance, or update your tax withholdings, please make the change in ADP.

I understand that I cannot change any of these elections for medical, dental, and dependent coverage until the next open enrollment period, unless I have qualifying change in status.
If I waived medical coverage, I certify that I have other medical coverage.
Payroll Deduction/Pretax Premium/Billing Agreement: I authorize T&M Associates and all its affiliates to deduct from my earnings the amount required to cover my share of the premium for these coverages. If I elect to participate in pretax medical and dental premiums, I authorize T&M Associates and all its affiliates to reduce my taxable income by an amount equal to my medical and dental premiums. If I am being billed, I understand that failure to pay my premium(s) will result in cancellation of coverage.
Waiver Agreement: After my initial enrollment period, I understand that in order to enroll in the future I may be required to provide evidence of insurability, and I may enroll in some plans only during open enrollment periods and/or be subject to pre-existing condition limitations.
Release of Information: I understand that certain information collected by T&M Associates, including some collected using this form, must be sent to the carriers of the plans in which I have enrolled. T&M Associates and the insurance carriers will treat this information as confidential.

Employee Signature*

Today's Date*

Date

2024 QUALIFYING LIFE EVENT FORM

MEDICAL INSURANCE, VISION, AND PRESCRIPTION

OTHER INSURANCE COVERAGE

HEALTH SAVINGS ACCOUNT (High Deductible Plan)

FLEXIBLE SPENDING ACCOUNT

DENTAL INSURANCE

VISION INSURANCE

EMPLOYEE DEPENDENT AND SPOUSE INFORMATION

AUTHORIZATION AND SIGNATURE