Hertz sample Initial Letter.pdf - ConSova

Dependent Verification Form
Please mail this completed and signed form and the requested verification documentation, in the enclosed
postage-paid envelope by Month Day, Year to ensure that coverage continues for your eligible
dependents.
Please check the appropriate box:
I have enclosed the requested documentation to verify the eligibility of my dependent(s).
I have an ineligible dependent(s) and have noted the reason below. I understand that their coverage
will end as soon as reasonably possible after this has been reported to Hertz.
Ineligible Dependent(s)
If any of your dependent(s) are no longer eligible for medical or dental coverage, please provide his/her
name(s) and the reason for ineligibility below. Coverage for ineligible dependents will end as soon as
reasonably possible after this has been reported to Hertz.
Ineligible Dependent Name
Ineligibility Reason
Signature of Employee:
Date:
By signing above, I certify and warrant to Hertz that all information on this Dependent Verification Form is true, correct and current
as of the date signed. I further understand that if I knowingly submit false information I may be subject to disciplinary action up to
and including termination of employment. I authorize Hertz and ConSova Corporation to contact any institution or organization to
verify any and all documents provided for eligibility verification.
Please mail this completed and signed form along with the requested
verification documentation.