Sample – Dependent Verification Introductory Letter - ConSova

Sample – Dependent Verification
Introductory Letter
April 29, 2013
John Smith
123 ABC Way
Anywhere, USA 99999
Dear John Smith:
As part of Rent-A-Center's ongoing efforts to keep the cost of insurance plans as affordable as
possible, we want to ensure that only eligible dependents are enrolled in the RAC plans.
We have partnered with ConSova, a company that specializes in verifying the dependents' eligibility
for inclusion in company benefit plans, to help us verify all dependents on RAC's benefit plans.
ConSova will be contacting every coworker who has a dependent covered by a RAC benefit plan and
asking for documentation to verify eligibility for coverage. The process is detailed in the attached
letter and FAQ's from ConSova.
We are making this dependent verification process as simple as possible. It is important that you
comply with the request for documents to verify your dependents. If you do not, then your
dependent's benefit coverage will end.
Please review the dependents listed on the enclosed letter and confirm their eligibility by submitting
the required documents by May 24, 2013. If you are missing a document, send in what you do have
to ConSova to start the process.
The documents needed to verify a dependent is covered in the letter from ConSova. Please review
the letter and requirements enclosed, If you have any questions, please contact ConSova at
(855) 625-3569 Monday through Friday, 9:00 a.m. – 5:00 p.m. Central Time.
Thank you for your cooperation and participation.
Sincerely,
Pete Bruni
Vice President – Compensation & Benefits
Rent-a-Center, Inc.
Caution: Form contains personalized encoded information. Do not share with others.

Frequently Asked Questions
Who is ConSova
ConSova is a firm that specializes in helping companies verify the dependents on their benefit plans. They have
performed audits for several Fortune 500 companies and verified over 1.5 million dependents.
Is every coworker being audited
Every coworker with dependents must provide the documentation for their dependents.
How do I know my personal documents are protected and kept secure
Security and confidentiality are a very serious matter and very important to us. We use several layers of
security to protect your information
1) The server that maintains the dependent eligibility systems and scanned images is located in a SOC II SOC 3
compliant secure data center in Denver Colorado.
2) Images are only available using a closed Local Area Network inside the ConSova domain and secure private
network.
3) Your part: protect your privacy and information by following the instructions provided for sending information
to us.
Over the past 8 years, 1.5 million dependents have been audited by ConSova without a single accusation or
allegation of failure to protect the personal information of our client's employees and coworkers. We take every
precaution to keep your information confidential.
Can I black out my financial information
Absolutely!
Can I black out Social Security Numbers
Please do not black out the last 4 numbers. (xxx-xx-1234)
Can Human Resources (HR) at the FSC or my local manager or HRD review my documents instead of
ConSova
Unfortunately, no. All coworkers will verify dependents with ConSova. Part of the process is that a single
standard is applied to every coworker's dependent.
How long will ConSova keep my information
Documents received are consolidated and maintained in a secure location accessible only to ConSova
employees. One month after the dependent verification process is completed, all documents are securely
shredded.
What happens to electronic documents
PDF or TIF files remain on our secure file server until the contract with your Employer mandates that they be
destroyed (deleted). At no time does any document sent using these methods exist as a hard (paper) copy.
What is sent to HR or Benefits from this process
The Benefits department will receive a list of dependents that are classified as either:
Verified/Eligible
Not Verified/Ineligible
What happens if I can't supply the documentation by the deadline
ConSova is here to help you and can grant an extension of time to obtain documents. However, if you do not
provide the required documentation, your dependent will be removed from the RAC benefit plans, including the
medical, dental, vision, prescription, and telemedicine.
We commit that we will help you through this process. If you have questions, call us at ConSova’s
Dependent Eligibility Verification Assistance Center at (855) 625-3569 Monday through Friday,
9:00 a.m. – 5:00 p.m. Central Time.
Caution: Form contains personalized encoded information. Do not share with others.

April 29, 2013
Dependent Eligibility Verification
Dear John Smith
As you know, access to group benefits and Rent-A-Center's financial subsidies to your Core Health
plan are an important part of your Total Rewards compensation package. It is important that the
benefit dollars RAC spends on subsidizing the cost of benefits are spent only on those dependents
that are eligible for coverage.
Rent-A-Center contributes to the costs of coverage for coworkers and their dependents on the RAC
healthcare plans to help keep the benefit plans as affordable as possible. Ineligible dependents on
the plan increase costs and use subsidies that belong only to RAC coworkers.
We show the following dependents covered on a RAC benefit plan. Only these listed dependents will
require verification:
Dependent Name Relationship YEAR of Birth
Alicia Smith Spouse 1956
Your Action Items
Review your list of dependents above
Complete and sign the enclosed Dependent Verification Form. Coverage for ineligible
dependents will end as soon as administratively possible. You will see the change on your
paycheck in about 3 weeks.
Return the completed forms by either:
Uploading documentation by logging into https://www.securewebhelp.com, you will need
your PIN number to log in to the website; your PIN number is located at the bottom left hand
corner of this letter or
Mail documentation in the enclosed postage-paid envelope with a postmark on or before May
24, 2013.
Our Action Items
Review your documentation
Mail you a letter regarding the status of your dependents and requesting any additional
information we need
Please Note: If you do not complete this process or fail to respond, your dependents will
be removed from benefits coverage.
If you have any questions about this process or need assistance, please call ConSova’s Dependent
Eligibility Verification Assistance Center at (855) 625-3569 Monday through Friday, 9:00 a.m. –
5:00 p.m. Central Time. You may also visit www.consova.com/rentacenter where you can view
general information and access your secure web portal login.
Thank you for your cooperation during this important initiative.
Sincerely,
ConSova Corporation
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Dependent Verification Form
Please mail this completed and signed form and the requested verification documentation, in the
enclosed postage-paid envelope by May 24, 2013 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 administratively possible.
Ineligible Dependent(s)
If any of your dependent(s) are no longer eligible for medical, dental, vision, prescription, and
telemedicine please provide his/her name(s) and the reason for ineligibility below. Coverage for
ineligible dependents will end as soon as administratively possible.
Ineligible Dependent Name
Ineligibility Reason
Signature of Coworker:
Date:
By signing above, I certify and warrant to Rent-A-Center 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 Rent-A-Center 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.
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Dependent
Relationship
Spouse
Your legally married
spouse of opposite or
same gender
(divorced spouses are
not eligible for
coverage)
Dependent Documentation Request
What You Need to Submit to ConSova
Copy of marriage certificate
Documents Required
AND
A copy of your 2012 tax return (front page through line 6 of Form 1040);
please black out the first five digits of your SSN and all financial information.
Note: if your spouse files married separately, head of household or single, you
will also need to submit their 2012 Form 1040 (front page through line 6).
Please black out any financial information and social security numbers. We only
need the last 4 digits of the coworker's SSN.
Domestic Partner
Your eligible, unrelated,
opposite gender
domestic partner
Child under age 26
• Your natural child,
legally adopted child,
or child in the
process of being
adopted;
• Stepchild;
• Child of your
domestic partner;
• A child whom you
have legal
guardianship of; or
• A grandchild so long
as the grandchild is
an IRS defined
dependent; or
• A child who is the
subject of a Qualified
* The enclosed Benefit Verification and Information Release Authorization Form
Copy of the RAC Domestic Partnership Affidavit signed by you and your partner
AND
AND
Designation of Domestic Partner as beneficiary for RAC Basic Life
Insurance and 401(k) Retirement and Savings Plan
Joint asset and a joint liability for example:
o Joint mortgage (both asset and liability)
o Joint lease (liability)
o Ownership of motor vehicle (asset)
o Checking account (asset)
o Joint auto loan (liability)
o Other financial account (asset)
AND one of the following:
Designation of Domestic Partner as primary beneficiary of the
coworker’s will
Durable power of attorney naming each other
Healthcare power of attorney naming each other
Please note: Proof of asset and liability documents need to be dated, at
minimum, one year prior to the date of this letter as proof that the relationship
is at least one year old. Medical-related documents will not be accepted as a
proof of dependency.
A copy of the following documents (varies by the relationship of the child to the
Coworker):
• Natural child or legally adopted child: State or county issued birth
certificate showing coworker’s name or signed court order
• Stepchild: State or county issued birth certificate showing parents’ names,
copy of your Marriage Certificate, and copy of your joint 2012 federal tax
return (front page only).
• Child of your domestic partner: State or county issued birth certificate
and proof of established Domestic Partnership.
• Grandchild: State or county issued birth certificate showing parents’ names
for child and grandchild and copy of your 2012 federal tax return (front page
only).
• Child whom you have legal guardianship: Signed Court Order and 2012
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Dependent
Relationship
Medical Child Support
Order (QMCSO)
issued to you.
Documents Required
tax return claiming the child as a dependent. Please be sure to leave the last
four digits of the dependent’s SSN visible.
• Child who is the subject of a Qualified Medical Child Support Order:
Signed Court Order
Please note: for unmarried disabled children aged 26 or over, in addition to the
birth certificate, we will also need a copy of your federal tax return claiming the
child (front page only).
If unable to provide any of the documents requested, the coworker will need to contact ConSova for alternative documents if
applicable.
Don’t Forget! Your response is required by May 24, 2013.
Would you like to receive ConSova communications electronically Simply log into ConSova’s website at
www.consova.com/rentacenter and select ConSova’s “Going Green” option at the top of the page to
learn more about our paperless option.
Caution: Form contains personalized encoded information. Do not share with others.