COVER SHEET

COVER SHEET
To:
Winston Benefits
Fax:
1-732-903-1158
Attached:
Dependent Verification Documents
Employee Name: ______________________________________________
Employee ID: _____________ Contact phone: _____________________
Total number of pages including this cover sheet: _______
All previously unverified and newly added dependents covered by the medical, dental, and/or
vision plans must be verified with supporting documentation. Please refer to the Required
Documentation grid for complete documentation details.
For each unverified or newly added dependent, you must fax or email this form along with the
required supporting documentation to Winston Benefits.
IMPORTANT: If you are faxing documentation you should retain a copy of the fax confirmation page
for your records.
Fax number:
1-732-903-1158
E-Mail Address:
ccabenefits@winstonbenefits.com
Complete verification documentation must be received within 15 days of your timely completed
enrollment or your unverified dependent(s) will not be covered and if applicable, your benefit
coverage tier will automatically be reduced.
Refer to the Required Documentation grid for complete documentation details.
DEPENDENTS
LAWFUL SPOUSE
Your spouse as defined by the state law in which
you were legally married, regardless of where you
currently reside
REQUIRED DOCUMENTATION
The choice of option 1 or 2:
1. Copy of your state issued marriage certificate AND
Copy of the first page of your current or previous
year’s federal tax return that includes your spouse
(you may conceal all financial information)
OR
Copy of your state issued marriage certificate AND
Current dated (within last 90 days) proof of
common residency such as a shared utility bill or
bank statement with the common address indicated
2. The first and signature pages (or e-file confirmation
page) of your current or previous year’s federal tax
return showing marital status that includes your
spouse (you may conceal all financial information)
CHILDREN
 Your dependent child up to the age of 26,
including:
o Natural born child
o Legally adopted child (including children
placed for the purpose of adoption)
o Stepchild who resides in your home
o Child related by blood or marriage for
whom you or your lawful Spouse is the
legal guardian
o Child for whom you or your lawful
Spouse are financially responsible for
health care coverage under the terms of a
Qualified Medical Child Support Order or
other administrative order
DEPENDENT CHILDREN WITH
DISABILITIES
Dependent children who are incapable of selfsustaining employment because of mental or
physical disability, and became so prior to age 26,
and is dependent on the employee for financial
support and care
Copy of the first and signature pages (or e-file
confirmations page) of your current or previous year’s
federal tax return that includes your child (you may
conceal all financial information) OR
 Natural Child – Copy of the child’s state issued
birth certificate showing the employee’s name as
parent.
 Stepchild - Copy of the child’s state issued birth
certificate showing the employee’s spouse’s name as
a parent AND a copy of the marriage certificate
showing the employee and parent’s name OR
stepchild affidavit AND birth certificate showing the
employee’s spouse’s name as parent.
 Legal Guardian, Adoption or Foster Child – Copy
of Affidavits of Dependency, Final Court Order with
presiding judge’s signature and seal, or Adoption
Final Decree with presiding judge’s signature and
seal.
 Documentation as noted for the “Child” dependent
type AND
 Notice of Award Letter from Social Security (SSI)
of Supplemental Security Disability (SSDI) of child
being found disabled. Please note that this
documentation only verifies the child’s eligibility
as a dependent, not the disability status of the child
AND
 Proof that the child resides with the employee.
Updated 12/11/2013