Life Event Change Form (QLE)

Collects qualifying life event details, supporting documentation, benefit change requests, and effective date information for HR review.

Employee Information

• Employee Name
• Employee ID
• Work Email
• Department

Qualifying Life Event Details

• Qualifying Life Event Type
• Date of Event
  Enter the date the qualifying life event occurred.
• Brief Explanation
  Describe the event and why it qualifies for a benefits change. Do not include unnecessary sensitive details.
• Describe the Other Event

Dependent Changes

• What changed?
• Number of dependents affected
• Dependent Details

Requested Benefit Changes

• Medical Coverage Change
• Requested Medical Change
• Dental Coverage Change
• Vision Coverage Change
• Health Savings Account (HSA) Change
• Describe Requested Benefit Changes
  List the coverage changes requested and any relevant details for HR review.

Supporting Documentation

• Supporting documentation attached
• Upload Supporting Documents
  Examples may include marriage certificate, birth certificate, adoption placement papers, divorce decree, or proof of loss of coverage.

Effective Date and Certification

• Requested Effective Date
  The effective date will be determined according to plan rules and HR approval.
• Certification
  I certify that the information provided is true and complete to the best of my knowledge.
• Employee Signature
• Additional Notes for HR