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(1)

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(2)

Common Law Spouse

Eligibility requirements:

• Your common law spouse under state law.

Document options for verifying eligibility: (provide one of the following)

• Notarized Affidavit of Common Law Marriage and Proof of Joint Ownership issued within last 6 months

• Notarized Affidavit of Common Law Marriage and Federal Tax Return issued within last 2 years listing common law spouse

Civil Union Partner

• Your civil union partner under state law.

Document verifying eligibility: (provide the following)

• Civil Union Partner Certificate and Proof of Joint Ownership issued within last 6 months

Biological Child

• Biological child, up to age 26

Document verifying eligibility:(provide the following)

• Government issued Birth Certificate (including parents’ names)

Disabled Biological Child

• Biological child, age 26 and over • Must be unmarried

• Must be medically certified as disabled • Must be financially supported by you

Document verifying eligibility: (provide the following)

• Government issued Birth Certificate (including parents’ names) and Federal Tax Return within last 2 years claiming child

Adopted Child

• Must be your adopted child, up to age 26

• Adoption Placement Agreement (including child’s date of birth) or Petition for Adoption (including child’s date of birth)

(3)

Disabled Adopted Child

• Must be your adopted child, age 26 and over • Must be unmarried

• Must be medically certified as disabled • Must be financially supported by you

Document option for verifying eligibility: (provide the following)

• Adoption Certificate (including child’s date of birth) and Federal Tax Return within last 2 years claiming child

Step-Child

• Must be your spouse’s child, age 26 and over

• Government issued Birth Certificate (including parents’ names), Government issued Marriage Certificate, and Federal Tax Return within last 2 years listing spouse

• Government issued Birth Certificate (including parents’ names) and Government issued Marriage

• Certificate (if married within the last 12 months)

• Government issued Birth Certificate (including parents’ names), Notarized Affidavit of Common Law

• Marriage, and Proof of Joint Ownership issued within last 6 months

• Government issued Birth Certificate (including parents’ names), Notarized Affidavit of Common Law

• Marriage, and Federal Tax Return within last 2 years listing common law spouse

• Government issued Birth Certificate (including parents’ names), Government issued Marriage Certificate, and a Proof of Joint Ownership issued within last 6 months

Disabled Step-Child

• Must be your spouse's child, age 26 and over • Must be unmarried

• Must be medically certified as disabled

• Must be financially supported by you and your spouse

• Government issued Birth Certificate (including parents’ names), Government issued Marriage Certificate, and Federal Tax Return within last 2 years listing spouse & claiming child

• Government issued Birth Certificate (including parents’ names), Notarized Affidavit of Common Law Marriage, Proof of Joint Ownership issued within last 6 months, and Federal Tax Return within last 2 years claiming child

• Government issued Birth Certificate (including parents’ names), Government issued Marriage Certificate, Proof of Joint Ownership issued within last 6 months, and Federal Tax Return within last 2 years claiming child

• Government issued Birth Certificate (including parents’ names), Notarized Affidavit of Common Law marriage, and Federal Tax Return within last 2 years Listing Common Law Spouse & claiming child

(4)

Domestic Partner Child

• Must be your domestic partner’s child, up to age 26

• Government issued Birth Certificate (including parents’ names), Notarized Affidavit of Domestic Partnership and Proof of Joint Ownership issued within last 6 months

• Government issued Birth Certificate (including parents’ names), Certificate of Domestic Partner Registration, and Proof of Joint Ownership issued within last 6 months

Domestic Partner Disabled Child

• Must be your domestic partner's child, age 26 and over • Must be unmarried

• Must be financially supported by you and your domestic partner

• Government issued Birth Certificate (including parents’ names), Notarized Affidavit of Domestic • Partnership, Proof of Joint Ownership issued within last 6 months, and Federal Tax Return

within last 2 years claiming child

• Government issued Birth Certificate (including parents’ names), Certificate of Domestic Partner • Registration, Proof of Joint Ownership issued within last 6 months and Federal Tax Return

within last 2 years claiming child

Civil Union Partner Child

• Must be your civil union partner’s child, up to age 26

Document options for verifying eligibility: (provide the following)

• Government issued Birth Certificate (including parents’ names), Civil Union Partner Certificate, and Proof of Joint Ownership issued within last 6 months

Civil Union Partner Disabled Child

• Must be your civil union partner's child, age 26 and over • Must be unmarried

• Must be financially supported by you and your civil union partner Document options for verifying eligibility: (provide the following)

• Government issued Birth Certificate (including parents’ names), Civil Union Partner Certificate, Proof of Joint Ownership issued within last 6 months, and Federal Tax Return within last 2 years claiming child

Legal Ward

• Must be your legal ward as ordered by the court, up to age 26 Document options for verifying eligibility: (provide the following)

(5)

Disabled Legal Ward

• Must be your legal ward as ordered by the court, age 26 and over • Must be unmarried

• Must be financially supported by you and your spouse

Document options for verifying eligibility: (provide the following)

• Government issued Birth Certificate, Court Ordered Document of Legal Custody, and Federal Tax Return within last 2 years claiming child

Foster Child

• Must be your foster child, up to age 26

Document options for verifying eligibility: (provide the following) • Government issued Birth Certificate and Foster Care paperwork

The above benefit descriptions describe the plan(s) generally, and in summary form only. In the event of a conflict