Dependent Coverage Form.

Participants, who first become newly eligible, or reinstated from a prior cover period through covered employment, can elect to enroll their eligible dependents for medical and vision coverage. Dependent coverage can also be added at any time (whether you are covered by employment or are self-paying for coverage - COBRA, Vested Beyond COBRA, or Medicare Supplemental) based on any of the life events listed on pages 4 and 5 under the Special Enrollment Situations section of the Health Summary Plan Description (SPD). Adding dependent coverage can also be done during the Plan's Annual Open Enrollment Period, November of each year, in which the coverage effective date will be January 1 of the following year.

If you elect dependent coverage, you are required to pay the applicable premium for dependent coverage. Also note you will lose dependent coverage if you fail to make a payment when due. The following form is to be completed for dependent coverage. When enrolling a dependent, you MUST provide proof of dependent status – for example, a marriage certificate, birth certificate, certification of student status, proof of residence and/or proof of financial dependency.

This form is only to be completed for Cigna coverage. HMO dependents can be added directly on the HMO's enrollment application.

Dependent Coverage Form (PDF, 44K) depcovfrm.pdf

FOR PARTICIPANTS COVERED BY EMPLOYMENT ONLY, THE LINK BELOW LISTS THE QUARTERLY PREMIUM RATES IN ORDER TO ENROLL YOUR DEPENDENT(S) UNDER THE HEALTH PLAN.

For Dependent coverage rates click here.

Different premium rates for medical/vision dependent coverage will apply for COBRA, Vested Beyond COBRA and Medicare Supplemental participants, which are not listed under the Quarterly Rate Dependent Chart. These rates can be located by clicking on the Health Care Payments, where the POS Self-Pay CIGNA tab, listed at the top of that web page, is to be selected. From there, you can view the rates by clicking the tab associated with the appropriate type of dependent coverage.

Payments for dependent coverage made by check are to be made payable to the Equity-League Health Trust Fund. To pay by credit card, click on the Health Care Payments for additional payment details.

For Domestic Partnership information and forms, please click here. The same dependent rates and payment details, whether you are covered by employment, or are self-paying for coverage, apply to Domestic Partnerships.

Please mail the competed form and proof of dependent status to:

Equity League Health Trust Fund
165 West 46 St, 14 th Floor
New York, NY 10036.

If a payment is made by credit card, please include a copy of your receipt, along with the form(s) and proof of dependent status. You may also fax this information directly to the Health Department at (212) 869-3323.

For any additional questions, please contact the Fund Office and a customer service representative within the Health Department can assist you.

You'll need the free Acrobat Reader to view these forms.