DEPENDENT & QUALIFIED FAMILY LIFE EVENT
*REQUIRED DOCUMENTATION FOR ONGOING ENROLLMENT*
Dependent Qualified Family Life Event Required Documentation 2022 September.docx
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CITY OF BALTIMORE
DEPARTMENT OF HUMAN RESOURCES
Employee Benefits
7 E. Redwood Street | 20th Floor
Baltimore, MD 21202
T (410) 396-5830 | TTY 711 | F (410) 396-5216
Instructions: Documentation is required for newly added dependents and family status changes. Complete this form and attach all required
documentation and return all materials within forty-five (45) days of your initial enrollment period, sixty (60) days of your qualified family life
event or before the last day of Open Enrollment. Dependents will be removed from coverage if all the required documentation is not received.
EMPLOYEE INFORMATION
First Name:
Last Name:
Social Security Number (last four digits only):
☐Employee ☐Retiree
Date of Birth:
Daytime Number:
Cell Number:
OPTIONS FOR SUBMITTING DOCUMENTATION
Upload documents to Workday:
https://workday.baltimorecity.gov/login
Fax documents to:
(410) 396-5216
Mail documents to:
DHR, Office of Employee Benefits
7 E. Redwood Street | 20
th
Floor
Baltimore, Maryland 21202
NEW DEPENDENT ENROLLMENT
Eligible Dependent
Relationships to
Employee / Retiree
Dependent
Eligibility
Criteria
Documentation for
Verification of Relationship
(Attach a copy of:)
Legal Spouse
Legally married as
recognized by the laws of
the State or jurisdiction
where such marriage is legal
Official Court-Certified State Marriage Certificate (The certificate must be certified and
dated by the appropriate State or County official, such as the Clerk of Court.)
Where can I get a copy of a certificate?
• From the court in the County or City where the marriage occurred
• Maryland: Department of Health Vital Statistics Administration
https://health.maryland.gov/vsa/Pages/Home.aspx
•
Out of State: VitalChek https://www.vitalchek.com/
Children
• Birth
• Adoption
• Stepchild
• Permanent
Guardianship
• Medical Child
Support Order
• Disabled Child
(at age 26 as of
December 31
st
)
• Under age 26 as of
December 31
st
• Required to reside in your
home
• May be married or
unmarried
• Provide 100% economic
support
• Over age 26 and incapable
of self-support due to
mental or physical
incapacity incurred prior to
age 26
• Birth: Official State Birth Certificate with name of employee/retiree as child’s parent
• Adoption: Official court documents and official State Birth Certificate
• Stepchild: Official court-certified State Marriage Certificate and official State Birth
Certificate with the name of the spouse of the employee/retiree as child’s parent
• Permanent Guardianship: Official court documents signed by a judge and official State
Birth Certificate
• Grandchild: Official State Birth Certificate of your child and grandchild showing line of
relationship, recent Income Tax Return claiming grandchild and the Certification of
Economic Support for Grandchildren Form
• Medical Child Support Order: Official Medical Child Support Order requiring
employee/retiree to provide health coverage signed by the child support officer or judge
• Disable Child: Original Disability Questionnaire Form
ENROLLMENT DUE TO A QUALIFIED LIFE EVENT
Qualified Life Event
Required Documentation (Provide a copy)
Loss of Other Coverage (Employee, Retiree, Spouse, Child) Letter from Employer or Medical Plan
TERMINATION OF COVERED DEPENDENTS DUE TO A QUALIFIED LIFE EVENT
Qualified Life Event
Required Documentation (Provide a copy)
Death of Spouse or Child Death Certificate
Divorce Divorce Decree
Gain of Other Coverage (Employee, Retiree, Spouse, Child) Letter from Employer or Medical Plan
Marriage of Dependent Child Official State Marriage Certificate
