PDF Downloadable

HEALTH/DENTAL/LIFE CHANGE FORMS

If you want to add a dependent, remove a dependent, submit a name change, or mailing address change you will need to download, print & complete all of the following 3 forms:

Heath Change Application

Dental Change Notice

Life Group Certificate Change Form

“IMPORTANT”

If you are adding or removing a dependent or submitting a name change, you MUST attach to your completed forms, supporting documentation of the qualifying event

(THE REASON) you are making this change. Note that all completed forms with supporting documentation must be received by the Risk Management department within

30 days of the qualifying event date! If more than 30 days has past, you have the opportunity to make your changes during open enrollment. Open enrollment is the one month out of the year (August 1^st – 31^st) you can make changes to your group health and life benefits without supporting qualifying event documentation. All open enrollment changes are effective beginning October 1^st of the current year.

Examples of Qualifying Event Documentation are as follows:

MARRIAGE CERTIFICATE

DIVORCE DECREE

DEATH CERTIFICATE

BIRTH CERTIFICATE OR HOSPITAL BIRTH RECORD(S)

ADOPTION PAPERS

MEDICAL SUPPORT NOTICE

LOSS OR GAIN OF INSURANCE DOCUMENT FROM DEPENDENTS EMPLOYER OR INSURANCE CARRIER

Please print, complete and return all originally signed forms to the following address:

Sumter County BOCC

Risk Management Department

910 North Main Street, Suite 217

Bushnell, FL 33513

352-793-0205