Active Health Summary Plan Description
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4.10 Eligible Dependents

The following table summarizes who may be enrolled in the Plan as an eligible dependent and the documentation required by the Administrative Office to process the enrollment. An eligible dependent may be covered under all benefits available to the Participant. Eligibility for benefits will continue in the case of dependent children up to the limiting age shown in the table below; eligible dependent children will continue to be covered for dependent life insurance benefits to age 26. An eligible Dependent includes any child for whom the Participant is the legal guardian or for whom the eligible Spouse of a Participant is the legal guardian. A detailed explanation of the eligibility requirements under the Plan follows this table.

Eligible Plan Participants Required Documentation
Spouse Copy of Marriage Certificate
Biological Children to age 26 Birth Certificate/Paternity Test/QMCSO
Step Children to age 26 Birth Certificate
Adopted Children to age 26 Adoption Affidavit
Permanently Disabled Children Birth Certificate/Paternity Test/ Adoption or Guardianship Affidavit
Child who is a ward under order of temporary or permanent guardianship Legal Guardianship
Temporarily Disabled Child Disability Application/Birth Certificate – Child subject to Temporary or Permanent Guardianship

Under this Plan, eligible Dependents are the legal spouse (this Plan does not recognize a common law spouse unless the common law marriage was established in a jurisdiction which permits the creation of common law marriages) of the Participant as described in the following section and the Participant's children (including a step child or a legally adopted child) under 26 years of age. As required by law, an eligible Dependent will include a child under age 18, when placed with an Employee for adoption. Coverage for a Participant's children will terminate at the end of the month in which the child reaches age 26, unless otherwise extended under the provisions of this Plan. An eligible Dependent includes any stepchild of the Participant, who is under 26 years of age, who depends upon the Participant for support and lives with the Participant in a regular parent-child relationship and is a dependent of the Participant within the meaning of Internal Revenue Code Section 152.

Participants must provide written proof to the Administrative Office of their legal dependents in order for Dependents to be eligible for the benefits of this Plan. For example, a copy of your marriage certificate for a spouse, a copy of a birth certificate for a child and a copy of a decree of adoption for an adopted child. Once enrolled, coverage for the Participant's children under age 26 and the lawful spouse under this Plan is not optional. There is no ability to subsequently terminate coverage under this Plan for enrolled eligible Dependents of any eligible Participant so long as the Dependent continues to be an eligible Dependent. Nothing in this Article is intended to modify the carrier's coordination of benefits provisions.

Dependent children of eligible participants are covered for life insurance benefits from birth to age 26.

If a child covered by this Plan becomes totally and permanently disabled prior to reaching his/her 26th birthday while dependent upon his/her parents for support, his/her eligibility shall be continued for the duration of his/her disability, under the member's eligibility.

Upon dissolution, divorce, legal separation, or annulment, a spouse ceases to be an eligible Dependent on the first day of the month following the month in which the final decree terminating the marital relationship, or providing for the legal separation, is issued. However, a spouse may continue to be eligible as a qualified beneficiary under this Plan if COBRA continuation coverage is timely elected, as more fully set forth in the COBRA section of this Plan. In order to avoid liability for benefit expenses of ineligible dependents, you should notify the Administrative Office of a dissolution, divorce, or annulment as soon as it occurs.