Life Event Change Form (QLE)

A form for employees to report a qualifying life event, submit supporting documentation, and request benefit election changes with an effective date.

Employee Information

• Employee Name
• Employee ID
• Work Email
• Department

Qualifying Life Event Details

• Type of Qualifying Life Event
• Date of Event
  Enter the date the life event occurred, not the date you are submitting this form.
• Brief Description of the Event
  Provide a short explanation of the event. Include only what is necessary for benefits administration.
• Describe the Other Qualifying Life Event

Dependent Changes

• Does this event involve a dependent change?
• Requested Dependent Action
• Dependent Name
• Relationship to Employee

Requested Benefit Changes

• Benefit Types to Update
• Requested Benefit Change Summary
  Describe the change you are requesting for each selected benefit type.
• Requested Coverage Level

Supporting Documentation

• Supporting Documentation Provided
• Upload Supporting Documentation
  Examples may include marriage certificate, birth certificate, adoption paperwork, divorce decree, or proof of loss of coverage.
• Reason Documentation Is Not Yet Available

Effective Date and Certification

• Requested Effective Date
  Enter the date you believe the benefit change should take effect. HR will confirm the final effective date based on plan rules.
• Certification
• Consent to Process Personal Information