Proprietary 8-23 36 QUALIFIED STATUS CHANGE If you select dental, vision, group life, long-term disability (LTD), Hospital Plan, Critical Illness, accident insurance, you must participate in the plan for the entire year unless you experience a qualified status change. If you have experienced a qualified status change within 31 days of the event, you may be eligible to make changes to your benefit elections, as long as the change is consistent with and appropriate with the change in status. Each such participant needs to complete the Change Your Benefits event online at www.farmersagentsbenefits.com and provide the supporting documentation as indicated below, for approval. The following table illustrates eligible status changes, and the supporting documentation required for each change: CHANGE IN STATUS DOCUMENTATION NEEDED MARRIAGE Copy of the marriage certificate BIRTH OR ADOPTION Copy of the birth certificate or adoption paperwork DIVORCE OR LEGAL SEPARATION Copy of the final judgment, divorce decree, or separation document LOSS / ADD OF GROUP COVERAGE Copy of the group coverage letter (with the start or end date) COURT ORDER Copy of the court order identifying court action COBRA COVERAGE ENDING (Prior occupation) Copy of the loss of coverage letter (with the end date) LARGE RATE INCREASE (Prior coverage other than Farmers Agents Benefits Program coverage) Copy of the coverage letter (showing proof of the increase) RELOCATION (Large coverage charges) Copy of the coverage letter showing proof of plan disruption or notice of a change in home address If you experience a qualified status change during the year, and wish to add, delete, or change coverage for you or a dependent, you must complete the Change Your Benefits event online at www.farmersagentsbenefits.com within 31 days from the date of the event.
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