Medical Plan - Remove Dependent/Spouse

Kaiser Form Version

Title Prefix

Please note, this form is for the Kaiser HMO Medical Plan.

Type of Enrollment / Change Requested

Select a Type

Remove Dependent

Remove Spouse / Domestic Partner

Member Information

Please enter YOUR (the member's) information here. Your dependent's information will be entered on the next page(s) if applicable.

Legal First Name

Middle Name

Last Name

Please enter your legal name as it appears on your driver's license or birth certificate.

Social Security Number

Confirm Social Security Number

Date of Birth

Please use mm/dd/yyyy format.

Marital Status

Member Address

Street Address

City

State

Zip Code

Country

Member Contact Information

Mobile Phone

Home Phone

Personal Email

LAFD Email

Remove Dependent?

Would you like to REMOVE a Dependent from the Medical Plan?

YesNo

Dependent Information

Qualifying Event Date

Please use mm/dd/yyyy format.

For example, the date of Marriage, Qualified Domestic Partnership, Birth, Adoption, Legal Guardianship. Refer to lafra.org/change-dependents for more information.

Legal First Name

Middle Initial

Last Name

Please enter dependent's legal name as it appears on their driver's license or birth certificate.

Social Security Number

Date of Birth

Please use mm/dd/yyyy format.

Gender

Relationship

Is Address Different From Member's?

YesNo

Street Address

City

State

Zip Code

Country

Calculated Address Override

Calculated Street Address

Calculated City

Calculated State

Calculated Zip Code

Calculated Country

Complete this section only if you are adding a child under legal guardianship.

A child under a legal guardianship who reaches the maximum age (generally age 18) may continue coverage until age 26 if the child continues to reside with you or your surviving spouse/domestic partner and the child is not eligible for coverage under any other group health plan, as an employee or otherwise.

Dependent under legal guardianship resides with the member?

Dependent under legal guardianship is eligible for other coverage?

Required Documentation

When removing a dependent, please upload one of the following copies of required documentation:

Proof of medical coverage

Contact LAFRA's Member Service Department if you have questions about the required documents:

lafra.org/contact-us

Are you ready to upload a file?

YesNo

Please Note:

This individual's application will not be processed until the required documents are received.

Required Documentation

Please select one:

Yes, I've uploaded the required documentation.No, I still need to provide documentation.

Requirement Name

Requirement Status

Should Run Required Document Step?

Benefit Coordination / Other Insurance Carrier Information

Do you or your dependents have any other insurance?

If “YES”, complete the following information for each existing coverage policy:

Policy Type (i.e. Medical, Vision)
Insurance Carrier or Medicare
Coverage Dates
Policy Number
Who Is Covered Under This Policy?

Other Coverage Information

Signatures

I DESIRE TO PARTICIPATE IN THE COVERAGES SELECTED AND HEREBY AUTHORIZE THE NECESSARY DEDUCTION FROM MY EARNINGS (IF ANY) REQUIRED TO COVER MY SHARE OF THE PREMIUM.

If at any time the amount of said charges should be changed by the Board of Trustees of the Los Angeles Firemen’s Relief Association, Inc., I hereby authorize the deduction from my salary or wages and the payment of the Los Angeles Firemen’s Relief Association for this purpose, such sum as may be specified by the Board of Trustees of the Los Angeles Firemen’s Relief Association. This authorization shall be effective until cancelled by me.

Member's Signature (Type Name)

Date

Please use mm/dd/yyyy format.

FEDERAL LAW P093-579 SECTION 7 RE: FEDERAL PRIVACY ACT AND USE OF SOCIAL SECURITY NUMBERS. THIS LAW REQUIRES YOU BE INFORMED WHEN ASKED FOR YOUR SOCIAL SECURITY NUMBER THAT IT MUST BE PROVIDED FOR USE IN EMPLOYMENT PERSONNEL AND PAYROLL PROCESSES. AUTHORITY FOR REQUIRING THIS INFORMATION IS BASED UPON PROVISIONS OF THE CITY’S PAYROLL AND PERSONNEL CANDIDATE PROCESSING SYSTEM OPERATIONAL PRIOR TO JANUARY 1, 1975 AND APPLICABLE FEDERAL LAW.

Hidden Fields

Case Medical Application Record Type Id

PPO Application Record Type Id

Kaiser Application Record Type Id

Campaign Id

Contact Id

Campaign Name

Campaign Record Type Id

LAFD Account Id

Member Services Queue Id

JavaScript

Household Account Record Type Id

SSN Check

Requirement Prefix

TO DELETE

Policy Type (i.e. Medical, Vision)

Insurance Carrier or Medicare

Coverage Dates

Policy Number

Who Is Covered Under This Policy?