Dependent Certification

PLEASE READ THIS ENTIRE DOCUMENT BEFORE COMPLETING AND SUBMITTING THIS FORM TO THE HR/BENEFITS OFFICE.

The purpose of this affidavit is to verify dependent eligibility and to notify you of changes in LCMC Health definition of an eligible dependent under our Medical (health) Plans. LCMC Health is requiring all employees with dependent coverage to complete this form upon enrollment.

Please complete the following information for each dependent you add to your health plan: DEPENDENT SEX BIRTHDAY SOCIAL OTHER INSURANCE COVERAGE (H W S D) FULL NAME (M/F) (MO/DAY/YR) SECURITY INCLUDING MEDICARE NUMBER (List Employer Name, Address, Tax ID Number, Name of Carrier, Eff. Date of Coverage & Group Number). If no other coverage, state NONE.

Eligible Classes of Dependents . A covered employee's spouse and children from birth to their 26th birthday regardless of student status or marital status. . A legally married spouse. LCMC Health may require documentation proving a legal marital relationship. . A child shall include natural children, adopted children or children placed with a covered employee in anticipation of adoption. Step-children may also be included as long as a natural parent remains married to the employee.

Acknowledgements: . I agree to repay any losses suffered by any companies or persons, including but not limited to LCMC Health, due to any false statement contained in this affidavit, and I understand those companies or persons may bring a civil action against me to recover those losses, including reasonable attorney's fees. . I agree to notify LCMC Health if there is any change in my status or if any of my dependents lose eligibility as attested in this affidavit, within 30 days of such change.

Changes to the above listed dependent(s) requires completion of the UMR’s Medical Form.

I have read and understand the above dependent eligibility provision and I understand that any false statement contained in this affidavit, including failure to provide updated information as required herein, may be grounds for termination of benefits and/or termination of employment.

______Signature of Employee Employee Number Date

______Employee name (print name)