Patient Protection and Affordable Care Act (PPACA)
Affidavit of Adult Dependent Eligibility
To Apply During Open Enrollment Period:Make your elections according to the instructions provided in your annual open enrollment packet. Complete this Affidavit with your dependent, have it notarized with valid supporting documentation in the presence of you and your dependent. Mail notarized Affidavit to the Benefit Department with valid supporting documentation by the deadline noted in your enrollment packet.
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To Apply Outside Open Enrollment Period (Qualifying Event):
Complete an Employee Benefit Change Request form, complete this Affidavit with your dependent, have it notarized in the presence of you and your dependent. Mail notarized Affidavit to the Benefit Department with valid supporting documentation for your qualifying event, as well as verification of your relationship to your dependent. The change form and all supporting documentation (including notarized Affidavit) must be received by the Benefit Department within 30 days of your qualifying event.
DECLARATION:
This adult dependent has no other means of group medical/Rx coverage available to him/her(e.g. his/her employer’s, spouse’s and/or domestic partner’s plan, as applicable). Should he/she become eligible for other medical coverage, I will notify the Kinder Morgan Benefit Department in writing within 30 days of eligibility of such other coverage by completing an Employee Benefit Change Request form to stop this dependent’s Kinder Morgan medical coverage.
The dependent information provided below is for my adult dependent who is eligible for medical coverage provided by the Kinder Morgan, Inc. Medical Plan in accordance with the PPACA.
EMPLOYEE INFORMATION:
Employee Name (Last, First, Middle): / Employee ID # (5 digits):Address: / City: / State: / ZIP:
ADULT DEPENDENT INFORMATION(all information is required; if employer information is not applicable, write “N/A”):
Dependent Name (Last, First, Middle): / Employer (if applicable):Date of Birth: / Age: / Address:
Social Security Number: / Marital Status: / City, State, ZIP:
Relationship: / Employment Status (full-time, part-time, etc.):
Home Address: / Hire Date:
City, State, ZIP: / Employer Contact Name / Phone:
Phone:
List all that apply: natural born child, step child, adopted child, foster child, full-time student, married natural born or step child
In addition to completing this Affidavit, you must attach valid supporting documentation confirming your relationship to this child. See Summary of Required Documents for examples of valid supporting documentation. All supporting documentation must be presented to Notary Public for review prior to notarization. Kinder Morgan reserves the right to request additional documentation in support of employee’s relationship to child and/or child’s eligibility for other medical coverage, on a case-by-case basis, as may be required.
OTHER ACKNOWLEDGMENTS AND SIGNED DECLARATION NOTARIZATION
Must be signed and dated in presence of notary.
As an employee of Kinder Morgan, I declare, under penalty of perjury, that all of the information I have provided on this form and within the required supporting documentation is true and correct and that my Adult Dependent is not eligible for other medical coverage which may be available through his/her employer’s, spouse’s and/or domestic partner’s plan, as may be applicable. I understand that any false or misleading statement made, or false or misleading documentation provided, will subject me to disciplinary action up to and including termination of employment and possible charges of fraud.
______Employee Signature
______
Date Signed / City of ______
County of ______
Sworn to before me at ______, this
______day of ______, 20____.
Notary Public ______
My Commission expires: ______, 20____.
As an Adult Dependent of a Kinder Morgan employee, I declare that I am not eligible for other medical coverage which may be available to me through an employer’s plan or my spouse’s employer plan (if applicable).
______Adult Dependent Signature
______
Date Signed / City of ______
County of ______
Sworn to before me at ______, this
______day of ______, 20____.
Notary Public ______
My Commission expires: ______, 20____.
Please complete this form, have it notarized and mail it to the following address:
Kinder Morgan, Inc.
Benefit Department
500 Dallas Street, Suite 1000
Houston, TX 77002
Keep a copy of this completed form and supporting documentation for your records.
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SUMMARY OF REQUIRED DOCUMENTS
Supporting documentation must be submitted to the Benefit Department for each dependent you enroll in a benefit plan within your 30-day new hire enrollment period. Although you may elect coverage for your dependents, enrollment for your dependents is contingent upon receipt of valid supporting documentation which must be received by the Benefit Department within 30 days of your new hire date. If you are unable to provide supporting documentation for your dependent(s) within your 30-day new hire enrollment period, your coverage level will be changed (if necessary) to accurately reflect enrollment based upon the dependents for whom you have submitted valid supporting documentation and this will be reflected on your Confirmation Statement. Please note: if your coverage level is changed, your premium will be adjusted.
By adding dependents, you attest to the fact that you understand Plan eligibility requirements and the dependents you enroll meet the requirements of an eligible dependent. If you add a dependent who does not meet eligibility requirements, you further understand and agree that you will be required to fully reimburse the plan or service provider the charges incurred by ineligible dependents.
Following are examples of documents required to prove dependent eligibility for the health and welfare benefit plans:
Proof of Marital Status
- Current Tax Return – Federal or State; page one only; financial information and the first 5 digits of social Security numbers can be blacked out. The form must show “married filing jointly” or married filing separately” with spouse’s name indicated.
- Couples married during the current calendar year; a copy of the Marriage Certificate is acceptable.
OR
- Marriage Certificate ANDProof of Joint Ownership (mortgage statement, credit card statements, car note, bank statement, or utility bills dating from any time in the last three months, or a rental/lease agreement or property tax dated within the last 12 months; auto insurance can name one spouse as the owner and one as a driver and must be dated within the last six months.)
Proof of Parent-Child Relationship
- Birth certificate/hospital record naming the child’s parent(s) and date of birth.
- Court-approved adoption papers (with signature or seal) or Adoption Placement Agreement and Petition for Adoption.
- Paternity test naming child’s parent(s).
- Court child support order that names the child’s parents.
Proof of Residency (Required for Stepchildrenenrolled in dental and/or vision,in addition to Proof of Parent-Child Relationship (above))
- Current Tax Return – Federal or State; naming the child listed as a dependent; page one only; financial information and the first 5 digits of Social Security Numbers can be blacked out. The “number of children who lived with you” must agree with the number of dependents you list on the return. If these do not agree, this document is not acceptable proof of residency.
- Child’s Drivers license or state ID.
- Report card, school registration, or emergency contact form (showing address).
- Birth certificate/hospital record showing your address (acceptable only for children under age five).
Proof of Full-Time Student Status (Required in addition to Parent-Child Relationship and Proof of Residency, if Stepchild)
College Student (19-24 years old)Documents must include name of dependent, name of school, time period enrolled, and number of credit hours.
- Verification of enrollment from the current or most recent term.
- Letter from school on letterhead stating that the dependent is a full-time student for the current or most recent term.
- Class schedule, registration, report card, transcript, or tuition bill for the current or most recent term.
High School Students (19 years or older)
- Letter from the high school on school letterhead identifying dependent as a student.
Proof of Domestic Partnership
- Affidavit of Domestic Partnership and three (3) types of supporting documentation as outlined on Page 1 of the affidavit located online under Benefit Forms.
Proof of Adult Dependent Relationship (up to age 26) (medical only per Patient Protection and Affordable Care Act (PPACA))
- Provide documentation for Proof of Parent-Child Relationship, above;
- If birth certificate is for a stepchild and your spouse is not a dependent, you must also provide Proof of Marital Status, above;
- PPACA Affidavit of Adult Dependent Eligibility (available online under Benefit Forms).
Who is NOT ELIGIBLE for healthcare coverage?
A former spouse after the final date of the divorce. / A child that you have not legally adopted.
A common law spouse. / A grand child
A parent, grandparent, or step-parent of eligible employee. / A newly-eligible dependent (spouse, child, re-qualified full-time student) resulting from a qualified family status change who is not reported to Benefit Department within 30 days of qualifying event.
* A child if married.
* A stepchild if they do not live primarily with you.
** A child 19 or over who is not a full-time student.
You must provide REQUIRED supporting documentation to enroll NEW dependents in any of the following plans: Medical (Rx), Dental, Vision, Optional Life or AD&D.
All required supporting documentation must be eitheremailed to the Benefits mailbox at OR faxed to (713) 495-7416 (be sure to include your name on the fax).
You may also mail the supporting documentation to:
Kinder Morgan, Inc.
Attn: Benefit Department
500 Dallas, Suite 1000
Houston, TX, 77002
Please send this to the Benefit Department only once
If you have questions, contact your Human Resources Representative or the Benefit Department at
(800) 525-3752, press 1 @ the prompt, and enter ext. 67474.
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