Sample – Dependent Verification Introductory Letter - ConSova

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.
Caution: Form contains personalized encoded information. Do not share with others.