The document is a notice from the union regarding health benefit coverage. [1] It informs participants that they will receive a notice in the mail about continuing health care coverage for themselves and dependents. [2] It states that the health plan trustees are conducting a dependent eligibility verification with Secova, and participants must submit proof of dependent eligibility to Secova by December 27. [3] It warns that if required documents are not submitted, coverage for the participant and dependents will be terminated starting in January 2012.

1. PLEASE POST - OFFICIAL UNION NOTICE
WATCH YOUR MAILBOX
FOR AN
IMPORTANT NOTICE
from
SECOVA
regarding
HEALTH BENEFIT COVERAGE
If you have not already received a Notice in the mail, you will be receiving
one shortly regarding continuing health care coverage for you and your
dependents.
The Trustees of the Health Benefit Plan have partnered with Secova to
conduct a confidential dependent eligibility verification.
Between now and December 27,2011, all participants with dependents
enrolled in the Plan must submit proof of dependent eligibility to Secova.
If you do not complete and submit all the required documents referenced in
the Notice you receive, you and your dependents will be terminated from
health 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. Rocky Mountain UFCW Unions
& Employers Health Benefit Plan
ADMINISTRATION OFFICE
P.O. BOX 447 Arvada, Co 80001-0447 (303)-430-9334
CONSEQUENCES OF COMMON LAW
A common law marriage is treated the same as a ceremonial marriage (or marriage for which you
received a license). Therefore, you should think carefully before completing this affidavit. The
consequences 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, attorney's 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 Wife
STATE 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. 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 Address
Subscribed and sworn to before me this ____________ day of _______________, 20 _____
by _____________________ and _____________________, who personally
appeared before me and who are personally known to me, a Notary Public in the State
of Colorado.
My commission expires: __________________________________________
__________________________________________
Notary Public
REINHART7978626_3CS:CS 11/03/11 2

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 FORM
Your medical benefits provide coverage for an eligible stepchild or child for whom you have been awarded custody
and control who are full time students through December 31st of the year in which they attain age 23. If such
dependent 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 eligible
employer-sponsored health plan other than a group health plan of a parent, may continue to be covered as a
dependent under the Plan until the December 31st the year such child attains age 23 if such child is a full-time
student.
Please note: This form must be completed by the employee and the school (school representative must sign
form-see page 2)
GROUP # 032 Rocky Mountain UFCW Unions' & Employers' Health Benefit Plan
EMPLOYEE NAME: SSN
ADDRESS:
DEPENDENT (STUDENT) NAME: BIRTHDATE
SCHOOL TERM: QUARTER/SEMESTER YEAR
PLEASE FORWARD TO THE APPROPRIATE COLLEGE OR UNIVERSITY
TO:
Name of College or University
You are authorized to release the information requested below relative to my full-time status.
Student Signature Date
Student Name SSN
YES NO
Student is/was a full time student during quarter/semester ________________________ 20
Student completed the school term listed above.
If did not complete term, give last date of attendance
Enrollment was for ________________ units (credits, hours, etc.)
Requirement for full-time status is __________________ units.
REINHART7978819_3CS:CS 11/03/11

5. SIGNED DATE
TITLE
ADDRESS
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 Absence
Effective 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 over
age 19 covered as a full-time post-secondary (i.e., not high school) student under the Plan who
loses their student status because they take a medically necessary leave of absence from school
may continue to be covered under the Plan for up to one year after the first day of the leave of
absence.
For purposes of this continued coverage, a “medically necessary leave of absence” means a
leave of absence from a post-secondary (i.e., after high school) educational institution, or any
change 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 required
under Michelle's Law will be the same coverage provided to dependent students over age 19
that remain enrolled in school.
If you believe your child is eligible for this continued coverage, the child’s treating physician must
provide a written certification to the Plan stating that your child is suffering from a serious illness
or 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 Michelle's Law and its
application to your dependent child.
REINHART7978819_3CS:CS 11/03/11 2

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 STATEMENT
In order to enroll your stepchild for coverage in this Plan, the following conditions must be met and
the 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 the
number 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 Birth
Subscribed and sworn to before me this _________________________day of __________________ 20____
By ____________________________________ who personally appeared before me and who is personally
known to me, a Notary Public.
My commission expires:
Notary Public
REINHART1357181_5CS:CS 11/03/11