Tate of Michigan Civil Service Commission




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S
CS-1766

REV 8/2007


tate of Michigan

Civil Service Commission


Employee Benefits Division


400 South Pine Street, P.O. Box 30002, Lansing, MI 48909



NOTIFICATION BY EMPLOYEE/RETIREE OF QUALIFYING EVENT

This form is used to notify the State of Michigan of a qualifying event and the name(s) and address(es) of family members who will be removed from insurances. Retain a copy for your records. EMPLOYEES ONLY return the completed form to MI HR SERVICE CENTER or to your Human Resource Office. RETIREES return the completed form to Office of Retirement Services, P.O. BOX 30171, LANSING, MI 48909.

Instructions: If this form is returned in a timely manner, the information will be used to notify the family members of their rights to continue insurance coverage(s). Please complete the top portion of this form and either Section I if you are recently divorced, or Section II if you have a dependent child no longer eligible. A portion of this information is protected by federal privacy laws and/or state confidentiality requirements.

PRINT OR TYPE



NAME OF EMPLOYEE/RETIREE (Last, First, MI)

     


SOCIAL SECURITY NO OF EMPLOYEE/RETIREE

     


ADDRESS OF EMPLOYEE/RETIREE (City, State, Zip)

     


EMPLOYEE ID NUMBER

     


I hereby notify the State of Michigan that the following event has occurred:

 Divorce – Complete Section I

 Dependent Child No Longer Eligible – Complete Section II

SIGNATURE OF EMPLOYEE/RETIREE


DATE (MM/DD/YYYY)

     


SECTION I – DIVORCE (Include copy of Judgment of Divorce)

NAME OF SPOUSE

     


SOCIAL SECURITY NUMBER

     


ADDRESS

     


DATE OF DIVORCE (MM/DD/YYYY)

     


CITY

     


STATE

  


ZIP CODE

     


WORK PHONE

(     )     -     



HOME PHONE

(     )     -     


Name(s) of Dependent Child(ren) being removed from coverage

LAST

FIRST

DATE OF BIRTH (MM/DD/YYYY)

SOCIAL SECURITY NO


     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

SECTION II – DEPENDENT CHILD NO LONGER ELIGIBLE

NAME OF CHILD

     


DATE INELIGIBILE (MM/DD/YYYY)

     


SOCIAL SECURITY NO

     


ADDRESS

     


REASON INELIGIBILE

     


CITY

     


STATE

  


ZIP CODE

     


WORK PHONE

(     )     -     



HOME PHONE

(     )     -     



DEPENDENT COVERED FOR LIFE TO AGE 23?

YES  NO 

DELETE (CHECK ALL THAT APPLY)

HEALTH  DENTAL  VISION  LIFE 

IMPORTANT NOTE: THIS FORM MUST BE RETURNED WITHIN 60 DAYS OF THE DATE OF THE EVENT


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