Request for Continuation of Coverage for Disabled Children

Request for Continuation of Coverage for Disabled Children
Please Note: This form is to be completed by the participant/member. The form must be accompanied by a Physician's Statement of Disability. Your child's physician can either fill out the form online, or fill out a paper form.
Will your child's physician be filling out the online form, or would they prefer to fill out a paper form?
If your child's physician is filling out the online form:

Please provide your child's physician with your email address and a link to the online form, located here. Once they have submitted the form online, you will receive an email, which has the Physician Statement of Disability Submission ID. You must provide this Submission ID to submit this form.
Physician Statement of Disability Submission ID
If your child's physician is filling out the paper form:

Please print the paper Physician's Statement of Disability form, located here, and provide it to your child's physician. Once they have completed the form, please upload it in the File Upload field below. Alternately, your child's physician can mail the form back to the address listed.
File Upload

Cancelof
Please note:

The uploaded file must be DOC, DOCX, PDF, GIF, JPG, PNG, TIFF or TIF in format. The uploaded file must be less than 28MB in size.

Renaming a non-supported file type to a supported file types will not be accepted. EXAMPLE: myreceipt.png to myreceipt.pdf

Please ensure the file name is 25 characters or less.
Participant/Member Name

First NameLast Name
Participant/Member ID #
Employer Name
Dependent Name

First NameLast Name
Dependent Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent Child's Physician Name

First NameLast Name
Dependent Child's Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
A. This certifies that:

1. {dependentName} is my unmarried child

2. {dependentName} cannot engage in any substantial gainful activity because of a physical or mental condition that has lasted or can be expected to last continuously for at least a year or can lead to death; and

3. {dependentName} is principally dependent upon me for support and maintenance.

B. I request continuance of insurance, which would otherwise terminate on attainment of the age limitation of the group policy.

C. I understand that no liability for claims exists with respect to any period prior to the receipt of this form.

D. I attest and/or consent to the following:

1. My child’s attending physician (name and address indicated below) may be contacted to obtain information concerning my child’s incapacity.

{dependentChilds}
{dependentChilds11}

2. The information given above is correct to the best of my knowledge and belief.

3. I understand that enrollment for this child under my coverage may remain in force only if the disability and dependency exist, and while my coverage is of the type which may include such a dependent child. I further understand that recertification may be required as to eligibility for continuing coverage from time to time as often as it is deemed reasonable.

4. I recognize that any cost associated with the release of this medical information will be at my expense.

5. Fraudulent information is cause for immediate or retroactive termination of coverage.
Participant/Member Signature

Please sign with mouse or finger if on mobile device.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: