The April 11 – June 18, 2014 Verification Period has ended. Employees who have not completed the DEV process by the June 18, 2014, deadline will have their dependent(s) removed from Flex medical and dental coverage effective July 14, 2014.Dependents removed as part of the DEV program may be added back to Flex coverage with supporting documentation at Open Enrollment in October 1-31 for coverage effective January 1, 2015. Employees who did not meet the June 18thdeadline and would like to appeal the removal of a dependent should complete this form. It is expected that appeals will be processed and responses provided in approximately 2-6 weeks from the date your appeal is received.
Please note: Submitting this DEV Appeal will not prevent your dependent from being removed on July 14, 2014. Coverage will be reinstated for your dependent effective the date your appeal is granted. Any expenses your dependent has after coverage is canceled will be your financial responsibility.
YOU MAY ATTACH ADDITIONAL PAGES IF NEEDED

Employee Name: / Employee ID#
Address: / Day Phone:
Email Address: / Date:
Dependent Name / Date of Birth / Relationship
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Part 1: REASON FOR APPEAL

Check the box that most appropriately describes the reason for your appeal:
Documents Submitted Were Not Accepted City Error In Receiving Documents Other (Specify) Late Submission Of Documents Did Not Submit DEV Form Documents Ordered, But Not Received in Time Legal Proceedings Delaying Documentation
Please describe the reason(s) you were unable to complete the DEV process by the June 18, 2014 deadline.

PART 2: REQUEST

Please describe what you are requesting and why. For example, are you requesting to:
  • Submit the acceptable supporting documentation after the June 18th deadline?
  • Submit alternative documentation to verify your dependents’ eligibility?
  • Resolve a clerical error that was made?

Part 3: Supporting DOcuments

Please list any supporting documents you have attached to this appeal form.

HOW to submit this appeal form (3 ways):

  1. Scan and Email to with the subject “DEV Appeal”
  2. Fax to (213) 978-1623
  3. Mail or drop off:
City of Los Angeles, Personnel Department, Employee Benefits Division
ATTN: DEV APPEAL
200 North Spring Street
City Hall, Room 867
Los Angeles, CA 90012
For Questions or Assistance, please call the Flex Benefits Call Center at 1-800-778-2133
For Office Use Only
Date Received:
Staff Initials:

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