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PLEASE POST - OFFICIAL UNION NOTICE                              WATCH YOUR MAILBOX                                       ...
Rocky Mountain UFCW Unions                  & Employers Health Benefit Plan                                      ADMINISTR...
5. We hereby publicly acknowledge that we are married, and we consent and agree to           be husband and wife and to as...
Rocky Mountain UFCW Unions                    & Employers Health Benefit Plan                                             ...
SIGNED                                                                                   DATETITLEADDRESS                 ...
Rocky Mountain UFCW Unions & Employers’               Health Benefit Plan                                         ADMINIST...
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  1. 1. PLEASE POST - OFFICIAL UNION NOTICE WATCH YOUR MAILBOX FOR AN IMPORTANT NOTICE from SECOVA regarding HEALTH BENEFIT COVERAGEIf you have not already received a Notice in the mail, you will be receivingone shortly regarding continuing health care coverage for you and yourdependents.The Trustees of the Health Benefit Plan have partnered with Secova toconduct a confidential dependent eligibility verification.Between now and December 27,2011, all participants with dependentsenrolled in the Plan must submit proof of dependent eligibility to Secova.If you do not complete and submit all the required documents referenced inthe Notice you receive, you and your dependents will be terminated fromhealth benefits coverage as of January 2012.If you have questions, please call Secova at 1-877-652-0380 (toll-free). Representatives are available Monday through Friday, 6:00 AM to 9:00PM MST.
  2. 2. Rocky Mountain UFCW Unions & Employers Health Benefit Plan ADMINISTRATION OFFICE P.O. BOX 447 Arvada, Co 80001-0447 (303)-430-9334 CONSEQUENCES OF COMMON LAWA common law marriage is treated the same as a ceremonial marriage (or marriage for which youreceived a license). Therefore, you should think carefully before completing this affidavit. Theconsequences of marriage apply equally to common law marriage, including: 1. Once formed, a common law marriage can be terminated only by death or divorce. There is no such thing as a "common law divorce." You must go to a Court and obtain a Court order of divorce. Upon divorce, either spouse may be required to pay separate maintenance, attorneys fees, child support for any child of the marriage, and the Court is free to apportion marital property on an equitable basis. Marital property includes any property acquired during the marriage regardless of how titled and the increase in value of the separate property of either spouse. 2. The common law spouse is entitled to inherit from the deceased spouse and cannot be disinherited. 3. In order to sign up another spouse under this Plan, we will require you to produce a Court order of divorce or death certificate. AFFIDAVIT OF COMMON-LAW MARRIAGE Between Husband and WifeSTATE OF COLORADO } :______ COUNTY ________ }___________________________________________________________________ ("Insured"),Social Security Number ________________________________________________________and __________________________________ ("Spouse"), DOB/______________________,of lawful agent being first duly sworn upon their oath, state as follows: 1. We currently reside together as husband and wife. 2. We have agreed to be husband and wife, and we hold ourselves out to the community in which we live as being married. 3. We are at least 18 years old. 4. There is no legal impediment to our marriage, including a prior ceremonial or common-law marriage of either of us that has not been legally terminated by death or divorce.REINHART7978626_3CS:CS 11/03/11
  3. 3. 5. We hereby publicly acknowledge that we are married, and we consent and agree to be husband and wife and to assume all legal responsibilities and duties of lawfully married persons. We understand that this marriage can only be terminated by death or divorce. 6. If either of you has previously been married (including common law married), please provide a copy of your divorce decree or the death certificate for your prior spouse. 7. The following children reside with us: Name Date of Birth Relationship to Insured 8. The Insured understands and acknowledges that the Board of Trustees of the Rocky Mountain UFCW Unions & Employers Health Benefit Plan must approve the dependent status of the Spouse or children are eligible to receive benefits under the Rocky Mountain UFCW Union & Employers Health Benefit Plan. FURTHER, Affiant sayeth not. Dated this _____ day of ___________________________ 20 _____. ________________________ ________________________ Name Name ________________________ ________________________ Address AddressSubscribed and sworn to before me this ____________ day of _______________, 20 _____by _____________________ and _____________________, who personallyappeared before me and who are personally known to me, a Notary Public in the Stateof Colorado.My commission expires: __________________________________________ __________________________________________ Notary PublicREINHART7978626_3CS:CS 11/03/11 2
  4. 4. Rocky Mountain UFCW Unions & Employers Health Benefit Plan ADMINISTRATION OFFICE P.O. Box 447 ● Arvada, CO 80001-0447 ● (303) 430-9334 FULL TIME STUDENT VERIFICATION FORMYour medical benefits provide coverage for an eligible stepchild or child for whom you have been awarded custodyand control who are full time students through December 31st of the year in which they attain age 23. If suchdependent is between age 19 and 23 and is a full time student, please complete and return this form. In addition,your natural child, legally adopted child or a child placed with you for adoption who is eligible to enroll in an eligibleemployer-sponsored health plan other than a group health plan of a parent, may continue to be covered as adependent under the Plan until the December 31st the year such child attains age 23 if such child is a full-timestudent.Please note: This form must be completed by the employee and the school (school representative must signform-see page 2)GROUP # 032 Rocky Mountain UFCW Unions & Employers Health Benefit PlanEMPLOYEE NAME: SSNADDRESS:DEPENDENT (STUDENT) NAME: BIRTHDATESCHOOL TERM: QUARTER/SEMESTER YEAR PLEASE FORWARD TO THE APPROPRIATE COLLEGE OR UNIVERSITYTO: Name of College or UniversityYou are authorized to release the information requested below relative to my full-time status. Student Signature Date Student Name SSN YES NOStudent is/was a full time student during quarter/semester ________________________ 20Student completed the school term listed above.If did not complete term, give last date of attendanceEnrollment was for ________________ units (credits, hours, etc.)Requirement for full-time status is __________________ units.REINHART7978819_3CS:CS 11/03/11
  5. 5. SIGNED DATETITLEADDRESS PLEASE RETURN FORM TO PLAN OFFICE AT ADDRESS ABOVE.____________________________________________________________________________ Michelle’s Law Notice Eligibility for Continued Coverage for Dependent Students on Medically Necessary Leave of AbsenceEffective as of May 1, 2010, Michelle’s Law applies to the Rocky Mountain UFCW Unions &Employers Health Benefit Plan (the “Plan”). Michelle’s Law provides that a dependent overage 19 covered as a full-time post-secondary (i.e., not high school) student under the Plan wholoses their student status because they take a medically necessary leave of absence from schoolmay continue to be covered under the Plan for up to one year after the first day of the leave ofabsence.For purposes of this continued coverage, a “medically necessary leave of absence” means aleave of absence from a post-secondary (i.e., after high school) educational institution, or anychange in enrollment of the child at the institution, that: 1. begins while the child is suffering from a serious illness or injury, 2. is medically necessary, and 3. causes the child to lose student status for purposes of coverage under the Plan.The coverage provided to dependent children during any period of continued coverage requiredunder Michelles Law will be the same coverage provided to dependent students over age 19that remain enrolled in school.If you believe your child is eligible for this continued coverage, the child’s treating physician mustprovide a written certification to the Plan stating that your child is suffering from a serious illnessor injury and that the leave of absence (or other change in enrollment) is medically necessary.Please contact the Plan office if you have any questions regarding Michelles Law and itsapplication to your dependent child.REINHART7978819_3CS:CS 11/03/11 2
  6. 6. Rocky Mountain UFCW Unions & Employers’ Health Benefit Plan ADMINISTRATION OFFICE P.O. BOX 447 Arvada, Co 80001-0447 (303)-430-9334 1-800-527-1647 STEPCHILD ENROLLMENT STATEMENTIn order to enroll your stepchild for coverage in this Plan, the following conditions must be met andthe required documents submitted to the Plan office. Until all documents are received and reviewed,your stepchild will not be eligible under the Plan as a Dependent. Please contact the Plan office at thenumber above if you have any questions regarding this form or the process.REQUIREMENTS FOR STEPCHILD COVERAGE; Stepchild must permanently reside with the Eligible Employee. A normal parent-child relationship must exist between the Eligible Employee and the stepchild. The stepchild must have been claimed as a dependent on the Eligible Employee’s federal tax return for the prior tax year. If the stepchild is between the ages of 19-23, he/she must be a full-time student at an accredited school or university (complete Full Time Student Verification Form).REQUIRED DOCUMENTATION;  This form must be signed, notarized and submitted to the Plan office  The Eligible Employee must submit a copy of the prior year’s federal tax return on which the stepchild is claimed as a dependent I, _____________________________________, am an Eligible Employee of the Rocky Mountain UFCW Unions & Employers Health Benefit Plan (Plan). I am enrolling the following stepchild(ren) in the Plan. I certify that a normal parent-child relationship exists between myself and each listed stepchild, that each listed stepchild permanently resides in my home, and that each listed stepchild was claimed as a dependent on last year’s federal income tax return (copy submitted with this form). Stepchild Name SSN Date of BirthSubscribed and sworn to before me this _________________________day of __________________ 20____By ____________________________________ who personally appeared before me and who is personallyknown to me, a Notary Public.My commission expires: Notary PublicREINHART1357181_5CS:CS 11/03/11

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