PLEASE READ IMPORTANT ENROLLMENT GUIDELINES ON Return to:

Chicago Public Schools

REVERSE SIDE The Office of Human Capital
Benefits Employee Services Team
320 N. Elizabeth Street, 1st Floor
Dependent Information Form (Please Print) Chicago, IL 60607
Mail Run #38

PURPOSE: Adding a Dependent (certified documentation required)

DEPENDENT:
Remove Dependent MEDICAL
Male
Changing Dependent information DENTAL
Female
Reinstatement VISION

Employee ID Number: ____________________________________________________

Employee Name___________________________________________________________________
Last First M.I.
For Employee Benefits Use only
Teacher
School or Dept.________________________________ Career Service If adding a dependent

DEPENDENT INFORMATION Verified: Yes No

Name: Medical Eligibility: _____________

___________________________________________________________________________
Last First M.I. Dental Eligibility: ______________
Social Security Number:
_____________________________________________________________
Date of Review: _______________

Gender: Male Female Birthdate: /_______/_________ By: _____________ Date: _______

mo day yr
Added: Yes No
Primary Care Physician Code________________________________________________________
If deleting a dependent:
OB/Gyn Code_____________________________________________________________________
Deleted: Yes No
Is dependent covered by any other health insurance? Yes No

______________________________________ ___________________________
By: _____________ Date: _______
Name of Insurance Company Insurance Policy Number
If changing information:
Is dependent currently receiving Medicare? Yes No
Changed: Yes No
If yes, check one: Part A only Part B only Both Part A & Part B
By: _____________ Date: _______
Date Medicare effective:
_____________________________________________________________
Employee Benefits
Is dependent mentally or physically disabled? Yes No
Comment Space
Is dependent a full-time student in an accredited community college, college or university?
Yes No

Are you changing dependent information? Yes No

If so, please state reason below:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

I hereby attest that all information is true and accurate. I also authorize the Chicago Public Schools
or its authorized representative to audit the completeness and correctness of medical bills I may
incur under coverage of Chicago Public School paid plans and to use claim information as required
for statistical purposes. I also authorize the Chicago Public Schools to deduct the required employee
contribution from my paychecks

__________________________________________ _______________________
Employee Signature Date

Benefits Employee Services Team

Revised 5/4/09
 IMPORTANT ENROLLMENT GUIDELINES

To enroll for health benefit coverage each employee who meets eligibility requirements must submit an
Employee Information enrollment to Employee Benefits within 31 days of his or her date of hire or reinstatement.

Enrollment forms and certified documents (explained below) are also required to add a spouse, domestic
partner, and/or eligible dependent(s).

If you submit an enrollment form more than 31 days after your hire date, reinstatement or
change in family status, enrollment will be delayed until the next Open Enrollment
following the date completed forms and certified documents, if applicable, are received.

It is your responsibility to submit health benefit enrollment forms and required certified documentation to Benefits
Employee Services Team, 320 N. Elizabeth Street, 1st floor, Chicago, IL 60607, Mail Run #38. There is no other
Chicago Public Schools department, agency or person authorized to accept enrollment paperwork or
documentation.

If you want your spouse, domestic partner and/or dependents to be covered as soon as they are eligible you
must do the following:

1) Submit a Spouse Information Form, Domestic Partner Information Form and/or Dependent Information Form
within 31 days of your date of hire, or change in family status (eligible family status changes are listed
below); and

2) Submit certified documentation to establish the person is your dependent within 31 days of your date of hire
or change in family status. (Note: for newborn dependents, a certified birth certificate is required within 90
days following the date of birth, if you have an eligible change in family status.)

All documents such as birth certificates, marriage certificate, divorce decrees, court orders, etc. must be
certified; photocopies will not be accepted. Your document(s) will be returned to you if you provide Employee
Benefits with a self-addressed stamped envelope.

Plan changes and dependent enrollment changes are allowed only during the annual open enrollment period.
You may add or delete a dependent during the year only if you have an eligible change in family status.

Eligible family status changes include the following events: Approval of Domestic Partnership, Termination of
Partnership, birth or adoption of a child, death, a dependent reaching the limiting age, and certain changes in
employment status.

If you have any questions regarding health benefit enrollment, please contact Benefits Employee Services Team
at (773) 553-2820.

Benefits Employee Services Team

Revised 5/4/09