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Benefits Change Form

BENEFITS INFORMATION


Benefits information and plan summaries are available online at www.stamfordpublicschools.org.  Hover over Staff, click Benefits, and then Benefit Plan Information.  

All insurance changes need a qualified event and this form and all necessary documentation must be submitted within 30 days of the qualified event. If your benefits forms are not submitted to the Benefits Administration Office within 30 days of your qualified event, you will not be permitted to enroll until the next Open Enrollment in November or if you experience another qualified life event change.

Spouse and dependent information must match employee coverage.

Dependent children may be covered until the end of the year that they turn 26. 

All forms and documentation must be approved by the benefits office before any changes can be processed.

WHEN COVERAGE BEGINS & OPEN ENROLLMENT

Coverage will begin the first of the month following when this form and appropriate documentation is submitted, premium contributions may have to be adjusted. 

Coverage for newborns will begin on the date of birth, premium contributions may have to be adjusted. 

  


Qualified Event Required Documentation Copy of Copy of
Copy of
Marriage/Civil Union - Enrolling/Adding Spouse Copy of State Marriage CertificateSpouse's Social Security CardFront Page past year 1040 Tax Return -
Marriage/Civil Union - Dropping CoverageCopy of State Marriage Certificate ---
Divorce - Enrolling in Coverage/ Dropping SpouseCopy of Front Page of Divorce Decree ---
Birth/Adoption - Enrolling in Coverage/ Adding Dependent Copy of Birth Certificate or Adoption Decree Dependent Social Security Card
-
Birth/Adoption - Dropping CoverageCopy of Birth Certificate or Adoption Decree---
Termination/Commencement of Spouse or Dependent Child's Employment - Add Spouse
Letter from Spouse's Employer on Company Stationary
State Marriage CertificateFront Page past year 1040 Tax Return
Spouse Social Security Card
Termination/Commencement of Spouse or Dependent Child's Employment - Add Dependent
Letters from Dependent's employer on Company Stationary Copy of Birthday CertificateDependent Child's Social Security Card -
Termination/Commencement of Spouse or Dependent Child's Employment - Drop coverage
Letters from Dependent's employer on Company Stationary
---
Change in Spouse or Dependent Child's Job Status (Part time to Full time or Vice Versa)Same as "Termination/Commencement of Employment"
Unpaid Leave of Absence by you, spouse or covered dependent 






QUESTIONS 

If you are unsure if you have a qualified event please contact the Benefits Office at (203)977-4196 or (203) 977-4975.

Employee & Family Information

Benefits Change Type *
Employee Name*

Date of Birth *
Street Address*
Do you have other insurance? *
Please specify type
Other Insurance effective Date
Please indicate your event type

Please ensure you provide documentation via upload below or sent within 30 days of the qualified event to the BOE HR Department via email to BOEBenefits@StamfordCT.gov or fax to (203) 977-4043.  

Employee Coverage*
Will you be enrolling or dropping a spouse today? *
Action*
Spouse Name*

Spouse Date of Birth*
Coverage*
No File Chosen
File uploads may not work on some mobile devices.
ie. Marriage Certificate, Court Documents, etc
No File Chosen
File uploads may not work on some mobile devices.
ie. Spouse Social Security card
No File Chosen
File uploads may not work on some mobile devices.
ie. front page of last years tax return
Will you be enrolling or dropping a dependent today? *
Action *
Dependent Name *

Dependent Date of Birth*
Coverage*
No File Chosen
File uploads may not work on some mobile devices.
ie. birth certificate
No File Chosen
File uploads may not work on some mobile devices.
ie dependent social security card
Will you be enrolling or dropping a second dependent today? *
Action*
Dependent Two Name*

Dependent Two Date of Birth*
Coverage*
No File Chosen
File uploads may not work on some mobile devices.
ie. birth certificate
No File Chosen
File uploads may not work on some mobile devices.
ie. dependent social security card
Will you be enrolling or dropping a third dependent today? *
Action*
Dependent Three Name*

Dependent Three Date of Birth*
Coverage*
No File Chosen
File uploads may not work on some mobile devices.
ie. birth certificate
No File Chosen
File uploads may not work on some mobile devices.
ie. dependent social security card
Will you be enrolling or dropping a fourth dependent today? *
Action*
Dependent Four Name*

Dependent Four Date of Birth*
Coverage*
No File Chosen
File uploads may not work on some mobile devices.
ie. birth certificate
No File Chosen
File uploads may not work on some mobile devices.
ie. dependent social security card
No File Chosen
File uploads may not work on some mobile devices.
No File Chosen
File uploads may not work on some mobile devices.

Employee Signature

Use your mouse or finger to draw your signature above
Date and Time Submitted
:  

Approval

Benefits Approval *
Coverage Change Effective Date *
Date/Time
:  

Human Resources Processing

Changes Made in...
Date Changed in Ceridian
Date/Time
:  
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