Enrollment Documentation

When you or your dependents enroll in the Retiree Health Plan from the Employee Health Plan, proof of eligibility may not be required. However, if a dependent is added or removed from the plan, the following documentation is required.

Marriage

To enroll a spouse, you must provide the following documentation within 60 days of the marriage:

• A New Dependent Enrollment Form.
• A copy of the certified marriage certificate.

Coverage for your spouse will begin on the first of the month following the completion of his or her enrollment. Coverage can be retroactive to the date of marriage if the appropriate monthly contributions are paid.

If your spouse has another group health plan, other health insurance coverage, COBRA Continuation Coverage, a Medicare Advantage Plan, or Medicare Supplemental Insurance (Medigap), he or she may decline initial enrollment in the Retiree Health Plan if a Notice To Decline Coverage Agreement is completed reserving his or her rights to the Retiree Health Plan. Your spouse may enroll in the Retiree Health Plan within 60 days of termination of the other health coverage if eligible (please see "Loss of Other Health Care Coverage."

Domestic Partner

To enroll a domestic partner, you must provide the following documentation within 60 days of establishing the domestic partnership:

• A New Dependent Enrollment Form.
• A copy of the Affidavit of Domestic Partnership.

Coverage for your domestic partner will begin on the first of the month following the completion of his or her enrollment. Coverage can be retroactive to the date the domestic partnership was established with the plan if the appropriate monthly contributions are paid (please see "Eligible Dependents."

If your domestic partner has another group health plan, other health insurance coverage, COBRA Continuation Coverage, a Medicare Advantage Plan, or Medicare Supplemental Insurance (Medigap), he or she may decline initial enrollment in the Retiree Health Plan if a Notice To Decline Coverage Agreement is completed reserving his or her rights to the Retiree Health Plan. Your domestic partner may enroll in the Retiree Health Plan within 60 days of termination of the other health coverage if eligible (please see "Loss of Other Health Care Coverage."

Newborn, Adopted, Legally Placed, or Stepchildren

To enroll a newborn or other dependent child, you must provide the following documentation within 60 days of the birth, marriage, establishment of the domestic partnership, adoption, or the date the child was legally placed in your care:

• For a newborn, a New Dependent Enrollment Form and a copy of the birth certificate that was certified by the Department of Vital Statistics. For natural children born out of wedlock, a Child Enrollee Questionnaire, a copy of the birth certificate that was certified by the Department of Vital Statistics, and the paternity affidavit or a copy of the judgment or decree establishing paternity are also required. Other documents may be required to determine the effective date of coverage for a child born out of wedlock (please see the definition of "children."
• For stepchildren, a New Dependent Enrollment Form, a copy of the certified marriage certificate, a Child Enrollee Questionnaire, and a complete copy of the appropriate divorce decree, parenting plan, and child support order.
• For a child who is placed for adoption, a New Dependent Enrollment Form and a certified copy of the placement report and petition for adoption that were filed with the court, or other documents confirming that the child was legally placed for adoption.
• For legally placed children, a New Dependent Enrollment Form and a copy of the Adoption Placement Agreement or a copy of the court order specifying legal custody.

Your newborn child will be eligible for coverage on the date of birth. If a child is placed with you for adoption, he or she will be eligible for coverage on the date of the placement for adoption as long as the child satisfies the eligibility requirements of this plan. If a child is legally placed with you by virtue of a court order, he or she will be eligible for coverage on the date of the court order. Stepchildren are eligible for coverage on the date the parent was enrolled in the plan. Please see "Eligible Dependents" for additional details about eligibility.

Legal Separation or Divorce

If you are divorced or legally separated, you must provide the following documentation:

• A new Enrollment Form.
• A complete copy of the divorce decree.
• If there are children, a complete copy of the parenting plan and child support order. Eligibility for your former or legally separated spouse and stepchildren ends on the last day of the month in which the legal separation or dissolution of marriage becomes final. However, your former or legally separated spouse and stepchildren may elect to continue coverage under COBRA Continuation Coverage for up to 36 months (please see "COBRA Continuation Coverage").

If, following a divorce, you want your former spouse to remain your life insurance beneficiary, you must designate your former spouse as your life insurance beneficiary on the new Enrollment Form.

A Qualified Medical Child Support Order (QMCSO) could have an effect on benefit coverage. Please notify the Trust Office if a QMCSO is part of a divorce proceeding (please see "Eligible Dependents").

End of Domestic Partnership

If you no longer satisfy the requirements of a domestic partnership, you must provide the following documentation:

• A new Enrollment Form.
• A Domestic Partnership Termination Form.

Eligibility for your former domestic partner and his or her children ends on the last day of the month in which the termination of the domestic partnership becomes final. COBRA Continuation Coverage is not available to your former domestic partner or the children of a former domestic partner.

If, following the end of a domestic partnership, you want your domestic partner to remain your life insurance beneficiary, you must designate your former domestic partner as your life insurance beneficiary on the new Enrollment Form.

Child's Loss of Eligibility

No documentation is required when a dependent child loses eligibility because he or she attained a limiting age. Your dependent children's eligibility ends on the last day of the month in which you, your spouse, your domestic partner, or your dependent child no longer satisfies the eligibility requirements of the plan (please see "Eligible Dependents," "Suspension of Coverage," and "Termination of Coverage."

Your dependent children may elect to continue coverage under COBRA Continuation Coverage for up to 36 months (please see "COBRA Continuation Coverage"). COBRA Continuation Coverage is not available to the children of a domestic partner.

Death of A Dependent

You should notify the Trust Office if a spouse, domestic partner or a dependent child dies. The Trust Office will provide you with the information necessary to submit a life insurance claim (please see "Life Insurance Benefits").

Death of Retiree

Your surviving eligible dependents may continue coverage under this plan if they (1) were enrolled as dependents under this plan at the time of your death, (2) satisfy the dependent eligibility requirements, and (3) make the required monthly contribution to the Trust Office.

If your dependent(s) declined enrollment when initially eligible to enroll under the special enrollment rights described in "Loss of Other Health Coverage," these special enrollment rights are unaffected by your death.

If you die, someone in your family should notify the Trust Office. When the Trust Office is notified of your death, your life insurance beneficiary will receive the information necessary to submit a life insurance claim (please see "Life Insurance Benefits"). A surviving spouse or domestic partner who remains enrolled under this plan must also complete a Life Insurance Beneficiary Designation—Surviving Dependent form naming a new life insurance beneficiary.

If the surviving spouse remarries, his or her eligibility and the eligibility of your (the retiree's) dependent children in this plan is unaffected. However, members of the surviving spouse's new family cannot enroll in this plan. Domestic partners cannot enroll new family members onto this plan.

Documentation

The Board of Trustees reserves the right to request documented proof of dependency at any time. Whenever documented proof of dependency or any other documentation is requested by the Trust Office, it must be received within 60 days of the request or eligibility and the dependent's right to enroll will be denied.