Safran USA, Inc. Sample Initial Letter.pdf - ConSova

Month Day, YearDear John Smith:Dependent Eligibility VerificationAs part of Safran USA’s initiative to control benefit costs, they have retained ConSova’s services toreview and verify eligibility for covered dependents.Dependent(s) you have included on Safran USA, Inc. sponsored medical and dental plans are listedbelow:Dependent Name Relationship Year of BirthMichelle Smith Spouse 1956Jane Smith Child 1990Your Action Items Review your list of dependents above and the detailed explanation of the documentation you will needto provide to verify eligibility for dependent(s) on the following pages.If any of your dependents listed above are no longer eligible for medical or dental coverage, pleaseprovide their names and the reason for ineligibility on attached Ineligible Dependent Form. Coveragefor ineligible dependents will end as soon as administratively possible.Upload documentation by logging into https://www.securewebhelp.com, you will need your PINnumber to log in to the website; your PIN number is located at the bottom left hand corner of thisletter. Or you may also mail documentation along with a copy of this letter in the enclosed postagepaidenvelope with a postmark on or before Month Day, Year.Please note: This is not a passive verification process. Non-response or incomplete documentation willresult in the termination of insurance coverage for your dependents. Once your submitted documentationhas been reviewed, ConSova will mail a letter to you regarding the updated status and if any additionalinformation is required.If you have any questions about this process or need assistance, please call ConSova’s DependentEligibility Verification Assistance Center at (855) 261-6215 Monday through Friday, 9:00 a.m. – 5:00p.m. Central Time.ConSova’s Privacy Policy can be found on our corporate website athttp://www.consova.com/privacy-policy.php.Would you like to receive ConSova communications electronically? Simply log into ConSova’s website atwww.consova.com/safran and select ConSova’s “Going Green” option at the top of the page to learn moreabout our paperless option.Thank you for your cooperation during this important initiative.Sincerely,ConSova CorporationCaution: Form contains personalized encoded information. Do not share with others.

Ineligible Dependent FormIf any of your dependent(s) are no longer eligible for medical or dental coverage, please providehis/her name(s) and the reason for ineligibility below. Or you may leave a comment on your secureweb portal with the dependents name and reason for ineligibility by logging intohttps://www.securewebhelp.com and clicking the “submit comment” tab. You will need your PIN numberto log in to the website; your PIN number is located at the bottom left hand corner of this letter.Coverage for ineligible dependents will end as soon as administratively possible.Ineligible Dependent NameIneligibility ReasonSignature of Employee:Date:By signing above, I certify and warrant to Safran USA, Inc. that all information on this Ineligible Dependent Form is true,correct and current as of the date signed. I further understand that if I knowingly submit false information I may be subjectto disciplinary action up to and including termination of employment. I authorize Safran USA, Inc. and ConSova Corporationto contact any institution or organization to verify any and all documents provided for eligibility verification.Please mail or upload this completed and signed form along with therequested verification documentation.Caution: Form contains personalized encoded information. Do not share with others.

DependentRelationshipSpouseYour legally marriedspouse(legally separated ordivorced spouses arenot eligible forcoverage)Domestic PartnerYour eligible, unrelateddomestic partnerDependent Documentation RequestWhat You Need to Submit to ConSovaCopy of marriage certificateDocuments RequiredANDA copy of your 2012 tax return from the most recent tax season (front pagethrough line 6 of Form 1040); please black out the first five digits of your SSNand all financial information. Note: if your spouse files married separately, headof household or single, you will also need to submit their Form 1040 from themost recent tax season (front page through line 6). Please black out anyfinancial information and social security numbers. We only need the last 4digits of the employee's SSN.Copy of the domestic partner affidavit (signed by you and your partner duringenrollment)ANDProof of dependency as evidenced by a copy of two of the followingdocuments:• Proof of shared residence via joint mortgage statement or rental agreement• Automobile title or registration showing joint ownership of vehicle• Joint checking, bank or investment account statement• Joint credit account statement• A will and/or life insurance policy which designates the other as primarybeneficiaryChild under age 26• Your natural child,legally adopted child,or child in theprocess of beingadopted;• Stepchild;• A child whom youhave legalguardianship of; or• A child who is thesubject of a QualifiedMedical Child SupportOrder (QMCSO)issued to you.An unmarried disabledchild aged 26 or overmay be eligible providedthe plan administratorhas approved thedisability.Please note: Proof of dependency documents need to be dated within 60 daysprior to the date of this letter and insurance and medical-related documents willnot be accepted as a proof of dependency.A copy of the following documents (varies by the relationship of the child to theEmployee):• Natural child or legally adopted child: State or county issued birthcertificate showing employee’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 federal tax return fromthe most recent tax season (front page only).• Child whom you have legal guardianship: Signed Court Order and yourfederal tax return from the most recent tax season claiming the child as adependent. Please be sure to leave the last four digits of the dependent’sSSN visible.• Child who is the subject of a Qualified Medical Child Support Order:Signed Court Order*For unmarried disabled children aged 26 or over, in addition to the birthcertificate, we will also need a copy of your federal tax return from the mostrecent tax season claiming the child (front page through line 6 of Form 1040).If unable to provide any of the documents requested, the employee will need to contact ConSova for alternative documents ifapplicable.Caution: Form contains personalized encoded information. Do not share with others.