| Reason for Change |
Insurance Premium Plan |
Dependent Care Plan |
| Death of Spouse or Dependent |
Yes |
Yes |
| Change in Legal Marital Status |
Yes |
Yes |
| New Child (birth, adoption or placed for adoption) |
Yes |
Yes |
| Increase in Health Insurance Premiums |
Yes (1) |
No |
| Gain or Loss of Employment (2) |
Yes |
Yes |
| Going from Full-Time to Part-Time (2) |
Yes |
Yes |
| Going from Part-Time to Full-Time (2) |
Yes |
Yes |
| Change in Work Schedule Due to Strike or Lockout |
Yes |
Yes |
| Return from or Commencement of Unpaid Leave of Absence (2) |
Yes |
Yes |
| Significant Change in Employed Spouse's Health Plan |
Yes |
No |
| Gain/Loss of Coverage under Participant or Dependent's Health Plan |
Yes |
No |
| Change of Employment Status Impacting Participant Eligibility for Health Plan |
Yes |
No |
| Unpaid Leave under the Family and Medical Leave Act of 1993 (3)(4) |
Yes |
Yes |
| Dependent Satisfies or Ceases to Satisfy Requirements for Unmarried Dependents |
Yes |
No |
| Change in Residence or Worksite of Employee (2) |
Yes |
Yes |
| Employee Entitled to Special Enrollment Rights under HIPAA (2) |
Yes |
No |
| Plan Receives Qualified Medical Child Support Order |
Yes |
No |
| A Change in Status Occurs that Entitles Employee to COBRA Coverage (2) |
Yes |
No |
| Employee/Dependent Medicare or Medicaid Eligibility Change (2) |
Yes |
No |
| Significant Change in Dependent Care Costs or Providers |
No |
Yes |
| (1) The plan will automatically increase or decrease, as the case may be, your share of premiums. If you wish, however, you may revoke your premium plan election. |
| (2) Also applies to spouse and dependents. |
| (3) Your share of premium payments can be made monthly while on FMLA leave. |
| (4) Applies to employers with 50 or more employees. |
