DOCUMENTS REQUIRED FOR DEPENDENTS - Login

1 You are REQUIRED to submit documentation for each dependent listed on your dependent Profile. The chart below identifies the DOCUMENTS you must submit to maintain coverage for your DEPENDENTS . Do not submit original versions of your dependent DOCUMENTS . Any documentation you submit will not be returned to you, therefore we ask that you submit photocopies of your dependent DOCUMENTS . For tax forms, you may black out all financial information and all but the last 4 digits of any Social Security DOCUMENTATION FOR SPOUSES pouseOne document must be provided to verify a spouseONE OF THE FOLLOWING: Official state marriage certificate (certified and dated by the appropriate State or County official, such as the Clerk of Court) representing the court in the County or City in which the marriage took place; OR Church/justice of the peace marriage certificate; OR US military marriage certificate.

2 OR Official foreign marriage certificateOR ONE OF THE FOLLOWING (if you are unable to submit a document from the list above): Copy of most recent (2014 or 2015) Federal Tax Return (Form 1040)* that shows the dependent listed as Spouse (copy of confirmation notice if filed online) REQUIRED DOCUMENTATION FOR CHILDRENN atural Born Child Natural/Biological child s official State birth certificate (which must show the CTDI employee as parent); AND REQUIRED Documentation for Spouse (see above) when the last name(s) of your dependent child(ren) do not match yours and you are not covering a spouse under your your last name changed after the birth of your child (as the result of getting remarried, for example), you must verify the tax dependency of the child(ren) to you by submitting a copy of your 2014 or 2015 Federal Tax Return (Form 1040) that includes the child(ren) or, if you do not claim the children as tax DEPENDENTS , copies of your divorce and marriage ChildPending adoption: Notice of placement for adoption provided on adoption agency letterhead.

3 AND Court order placing child pending final adoption: Final adoption decree signed by a judge OR a State-issued birth certificate (showing the CTDI employee as parent), OR state certificate of identification for child of foreign birth (showing the CTDI employee as parent); AND REQUIRED Documentation for Spouse (see above) when the last name(s) of your dependent child(ren) do not match yours and you are not covering a spouse under your (must reside with the employee at least 50% of the time) Child s official State birth certificate (must indicate spouse as parent); AND REQUIRED Documentation for Spouse (see above) showing the names of the employee and spouse; AND Applicable divorce decree or legal custody note: If no divorce decree or custody papers are available, you must attach along with the marriage and birth certificates identified above - proof of the stepchild s residence with the employee ( school records, driver s license, day care records, etc.)

4 CONTINUED ON BACK/NEXT PAGEDEPENDENT AUDITDOCUMENTS REQUIRED FOR DEPENDENTSREQUIRED DOCUMENTATION FOR CHILDRENL egal Ward/GuardianshipEITHER: 1. Court order signed by a judge or other court official confirming that the employee has permanent legal custody of the child by a court order of custody or guardianship; OR2. Will providing testamentary appointment, confirming that the employee has legal custody of the Medical Child Support OrderCourt order requiring employee to provide support and health coverage, signed by the child support officer or judge. This documentation is REQUIRED when support is ordered for biological and adopted children and stepchildren. If you are submitting an order for the first time, it must have been issued within the past 60 Review your personal dependent Profile. Your profile is included within this kit, and it contains the names of the DEPENDENTS who must be verified as part of this Once you have gathered copies of your DOCUMENTS , you can submit them along with your signed dependent Profile via: FAX to 1-866-406-6946.

5 This is the fastest way to submit your DOCUMENTS ! UPLOAD Log into the Online Benefits Center at From the Home Page, select dependent Verification. Use the Upload dependent Documentation tool to locate the file you wish to upload. Once the file is identified, select Upload. A message will display informing you that your document has been successfully uploaded. You can then proceed with uploading additional files. MAIL Use the enclosed envelope to mail your DOCUMENTS . Please mail your DOCUMENTS 3-5 days in advance of the deadline when using this submission Watch your mailbox for additional information. You will be contacted again by mail after your DOCUMENTS are successfully verified or to notify you if any of the documentation you submit is unable to be verified.

6 SUBMISSION INSTRUCTIONSIf you have any questions regarding this verification process, please call theVantagen Employee Benefits Service Center at 1-800-307-0230. Representatives are available each Monday through Friday from 8:30 to 5:30 you decide to not participate in this verification process, or if your DEPENDENTS cannot be verified by the conclusion of the process, any coverage you currently maintain for the applicable dependent (s) named on your personal dependent profile will be terminated prior to your effective date. FAMILY MEMBER ELIGIBILITY AUDITQUESTIONS