Fillable Printable 2016 CCA Fax Cover Doc Requirements
Fillable Printable 2016 CCA Fax Cover Doc Requirements
2016 CCA Fax Cover Doc Requirements
FAX COVER SHEET
To: Winston Benefits
Fax: 1-732-903-1158
Attached:Dependent Verification Documents
Employee Name: ______________________________________________
Employee ID: _____________ Contact phone: _____________________
Total number of pages including this cover sheet: _______
All previously unverified and newly added dependents covered by the medical, dental, and/or vision
plans must be verified with supporting documentation. Please refer to the Required Documentation grid for
complete documentation details.
For each unverified or newly added dependent, you must fax, email or upload this form along with the
required supporting documentation to Winston Benefits.
IMPORTANT: If you are faxing documentation you should retain a copy of the fax confirmation page for your
records.
Fax number:
1-732-903-1158
E-Mail Address:
ccabenefits@winstonbenefits.com
Upload Documents:
Dependent Audit tab of
www.myccabenefits.com
Open Enrollment Elections: Complete verification documentation must be received no later than Monday,
February 15, 2016 or your unverified dependent(s) will not be covered and if applicable, your benefit coverage
tier will automatically be reduced.
New Hire/Life Event Elections: Complete verification documentation must be received within 15 days of
making your new hire/life event election or your unverified dependent(s) will not be covered and if applicable,
your benefit coverage tier will automatically be reduced.
NOTE: You are responsible for submitting all documentation to WB and for confirming with WB that all
documentation has been received, approved, and processed.
Refer to the Dependent Verification Required Documentation Chart for a list of acceptable documentation.
DEPENDENT VERIFICATION REQUIRED DOCUMENTATION CHART
DEPENDENTS REQUIRED DOCUMENTATION
LAWFUL SPOUSE
Your spouse as defined by the law of the jurisdiction in which you were
legally married, regardless of where you currently reside
The choice of option 1 or 2:
1. Copy of your state issued marriage certificate AND
Copy of the first page of your most current federal tax
return that includes your spouse (you may conceal all
financial information)
OR
Copy of your state issued marriage certificate AND
Current dated (within last 90 days) proof of common
residency such as a shared utility bill or bank statement
with the common address indicated
2.The first and signature pages (or e-file confirmation
page) of your most current federal tax return showing
marital status that includes your spouse (you may
conceal all financial information)
COMMON LAW SPOUSE
Common law applies in Alabama, Colorado, Iowa, Kansas, Montana,
Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, Utah
and Washington, D.C.
* Georgia - common law relationship created prior to 1/1/97
* Idaho - common law relationship created prior to 1/1/96
* Ohio - common law relationship created prior to 10/10/91
* Pennsylvania - common law relationship created prior to
1/1/05
Notarized copy of the CCA – Affidavit of Common Law
Marriage ANDCurrent dated (within last 90 days) proof of
common residency such as a shared utility bill or bank
statement with the common address indicated.
CHILDREN
Your dependent child up to the age of 26, including:
oNatural born child
oLegally adopted child (including children placed for the
purpose of adoption)
oStepchild who resides in your home
oChild related by blood or marriage for whom you or your
lawful Spouse is the legal guardian
oChild for whom you or your lawful Spouse are financially
responsible for health care coverage under the terms of a
Qualified Medical Child Support Order or other
administrative order
Copy of the first and signature pages (or e-file confirmations
page) of your most current federal tax return that includes
your child (you may conceal all financial information) OR
Natural Child – Copy of the child’s state issued birth
certificate showing the employee’s name as parent.
(Hospital birth certificate will be accepted for newborns
up to age 6 months).
Stepchild - Copy of the child’s state issued birth
certificate showing the employee’s spouse’s name as a
parent ANDa copy of the marriage certificate showing
the employee and parent’s name AND a signed and
notarized CCA Stepchild Affidavit
Legal Guardian, Adoption or Foster Child – Copy of
Affidavits of Dependency, Final Court Order with
presiding judge’s signature and seal, or Adoption Final
Decree with presiding judge’s signature and seal.
DEPENDENT CHILDREN WITH DISABILITIES
Dependent children who are incapable of self-sustaining employment
because of mental or physical disability, and became so prior to age 26,
and is dependent on the employee for financial support and care
Documentation as noted for the “Child” dependent type AND
Notice of Award Letter from Social Security (SSI) of
Supplemental Security Disability (SSDI) of child being
found disabled. Please note that this documentation
only verifies the child’s eligibility as a dependent, not
the disability status of the child AND
Proof that the child resides with the employee.
Updated 12.01.2015
