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Step 1 of 2
Change of Status Form
Request to Change Benefit Enrollments

Note: Changes must be requested within 60 days of the Event Date

INSTRUCTIONS: Changing your benefit enrollments is a two-step process. Step 1 initiates the process and consists of completing and submitting this interactive Change of Status form. If you prefer to supply this information by mail or in person, print a PDF of this form and fill it out manually. Fields with * are required. Step 2 is when you request the actual change in plan coverage. Upon approving your Change of Status form, Human Resources will generate a personalized benefit enrollment form for you. You will complete your elections on this form and attach any required documentation. After you return the form, the HR office will finalize your status and benefit changes. > Go to the HR Benefits Change Connection for more info
Employee information
*Name:		*University ID (not your SSN):
*Campus:	*Campus phone:	*Campus e-mail address:
*Department:
Reason(s) for change in benefits enrollment. Check any and all that apply.

	Event	Event Date	Documentation that will be required in Step 2
Family Change
	Birth or adoption		Copy of birth certificate or custody/adoption order
	Marriage of employee		Copy of marriage certificate, and if dropping IU coverage, documentation of enrollment in spouse's plan(s)
	Divorce/legal separation		Copy of part of the divorce order showing date
	Domestic partnership Begin End		Copy of notarized Affidavit of Domestic Partnership or Termination of Domestic Partnership.
	Death of spouse/child		Copy of death certificate
	Change in residence
	change HMO network		IU Change Form, Personal Data - PDF \| Online
	arrive/depart USA		Copy of passport or immigration documentation
	other		Describe:
	Dependent care provider or cost		Letter from provider
Dependent Child Change (check the box that best describes the nature of the change)
	Marriage of child		Copy of marriage certificate
	Student status (full time) Begin End		Certification of Eligibility for Dependent Child Age 19 or Older
	Reaches age 24		None needed
	Disabled child age 19 or above		Certification of Disabled Dependent Child Eligibility
	No longer meets the IRS financial support test		None needed
Employment Status Change
	Leave of absence Begin End		None if IU; if not, documentation of date eligibility ends with spouse's employer
	Involuntary loss of outside coverage		Notice from outside insurance provider of date of coverage ending, e.g. HIPAA coverage notice
	Begin spouse's employment/benefits at: IU Elsewhere		None if IU; if not, written notice from spouse's employer
	Loss of or change in spouse's employment or benefits IU Elsewhere		None if IU; if not, documentation of date eligibility ends with spouse's employer
	Significant change in premium cost (generally 10% or more) of the spouse's coverage		Written notice from spouse's employer
	Open enrollment at spouse's employer		Written notice from spouse's employer
Court Order/Government Program Change
	Guardianship or support order		Copy of court order
	Medicaid or Medicare		Written notice from government agency
COBRA If you are submitting this form due to divorce/separation, end of domestic partnership, or child no longer eligible for coverage, please provide the address of the dependent as he/she may be eligible for continued coverage through COBRA.
Signature
Typing my name in the space provided constitutes an electronic signature and certifies that the information supplied on this form is true and correct. I understand that intentionally providing false information or statements will be grounds for IU to void my coverage and/or terminate my employment. Employee signature: Delivery of personalized benefit enrollment form (step 2, available in 3-5 days): Please mail to my campus address I will pick up at the campus HR office (you will be notified when the form is ready)

Form updated: August 2006