All changes, personal or coverage amounts, made for Member’s that participate in the Basic, Optional and Family Insurance Plan(s) must complete the Blue Cross/MEBP Insurance Change form. This form is available under FORMS – Blue Cross/MEBP Insurance Section on the MEBP website.
The following changes are to be reported on this form:
- Change of name
- Increase or decrease coverage under Basic Life
- Add, increase, decrease or cancel coverage under Optional Life
- Add or delete coverage under Family Life
- Change of beneficiary under Basic and Optional Life
- Reporting marital status change is only required if the employee wishes to apply for Family Life Coverage.
Only the areas on the form that are affected by the change need to be completed.
The Member must sign and date the form. The Employer must indicate "Date of Change" in the Employer section of the form. This is the date that MEBP will use when initiating the changes requested by the Member. The signed original form should be sent to the MEBP Administration Office, a copy given to the Member and a copy can be kept on file. These forms should not be sent directly to Blue Cross, all forms should be forwarded to the MEBP Administration Office.
Changes to Insurance Coverage – Basic Life
Have the Member complete the Blue Cross/MEBP Insurance Change form.
To decrease Basic Life Coverage from 2x to 1x Annual Earnings:
- Have the Select the "Type of Change" on top of the form.
- Complete Name and Address, Gender and Date of Birth.
- Under "Basic Life Coverage", check box "Option 2".
- Complete the Beneficiary Designation area, sign and date by Employee.
- Employee to complete Authorization of Change and date.
- Employer section to be completed, signed and dated.
If the Member also has Optional Life insurance, it would automatically STOP and no further contributions should be deducted. Optional Life insurance is only available if the Employee has 2 units of Basic Life coverage.
To increase Basic Life Coverage from 1x to 2x Annual Earnings:
If a Member elected to be insured for 1x annual earnings and later decides to increase the coverage to 2x, an application has to be made to the Insurance Carrier, through MEBP. The Member will be required to provide evidence of good health and possibly see a medical examiner in order to satisfy the Insurance Carrier of proof of good health. This request for medical information will be sent to the Employee by the Insurance Carrier once they receive this form.
- Have the Member check off the "Type of Change" on top of the form.
- Complete Name and Address, Gender and Date of Birth.
- Under "Basic Life Coverage", check off "Option 1".
- Complete the Beneficiary Designation area, sign and date by employee.
- Employee to complete Authorization of Change and date.
- Employer section to be completed, signed and dated.
- Provide current salary in order to calculate coverage amount in a cover letter.
If the Member also wishes to now apply for Optional Life insurance, have them check off "ADD" and either "Option 1 or 2" in the Optional Life section of the form. Optional Life insurance is only available if the Member has 2 units of Basic Life coverage. Approval from the Insurance Carrier needs to be received before Optional Life Contributions can be deducted.
Changes to Insurance Coverage – Optional Life
Have the Member complete the Blue Cross/MEBP Insurance Change form.
Reminder: Optional Life insurance is only available if the Member has 2 units of Basic Life coverage.
If the Member originally decided not to apply for Optional Life at the time of initial enrollment with MEBP and now wishes to apply:
The Member will be required to provide evidence of good health and possible see a medical examiner in order to satisfy the Insurance Carrier of proof of good health. This request for medical information will be sent to the Employee by the Insurance Carrier once they receive this form.
- Have the Member check off the "Type of Change" on top of the form.
- Complete Name and Address, Gender and Date of Birth.
- Under "Optional Life Coverage", check off "ADD" and the "Optional Life Option 1 or 2" they wish to apply for.
- Complete Beneficiary Designation section, sign and date by employee.
- Employee to complete Authorization of Change and date.
- Employer section to be completed, signed and dated.
- Provide current salary in order to calculate coverage amount in a cover letter.
If approved, MEBP office will contact Employer with Effective Date and Contribution for payroll deduction.
To decrease Optional Life Coverage from 2x to 1x Annual Earnings:
- Have the Member check off the "Type of Change" on top of the form.
- Complete Name and Address, Gender and Date of Birth.
- Under "Optional Life Coverage", check off "CHANGE" and the "Optional Life Option 2”.
- Complete Beneficiary Designation section, signed and dated by employee.
- Employee to complete the Authorization of Change and date.
- Employer section to be completed, signed and dated.
Once form is received, MEBP office will contact Employer with Effective Date and new Contribution for payroll deduction.
To increase Optional Life coverage from 1x to 2x Annual Earnings:
- Have the Member check off the "Type of Change" on top of the form.
- Complete Name and Address, Gender and Date of Birth.
- Under "Optional Life Coverage", check off "CHANGE" and the "Optional Life Option 1”.
- Complete Beneficiary Designation section, signed and dated by the employee.
- Employee to complete Authorization of Change and date.
- Employer section to be completed, signed and dated.
- Provide current salary in order to calculate coverage amount in a cover letter.
The Member will be required to provide evidence of good health and possibly see a medical examiner in order to satisfy the Insurance Carrier of proof of good health. This request for medical information will be sent to the Employee by the Insurance Carrier once they receive this form.
If approved, the MEBP office will contact Employer with Effective Date and new Contribution for payroll deduction.
To cancel Optional Life coverage:
- Have the Member check off the "Type of Change" on top of the form.
- Complete Name and Address, Gender and Date of Birth.
- Under "Optional Life Coverage", check off "DELETE".
- Employee complete the Authorization of Change and date
- Employer section to be completed, signed and dated.
Deductions for Optional Life contributions cease effective the "Date of Change" indicated by the Employer at the bottom of the form.
The Member has QUIT SMOKING for at least 1 year and wants non-smoker rates:
The Member needs to complete a BLUE CROSS - Non-Smoker Questionnaire. This form can be requested from MEBP Administration office and once completed, the form must be returned to MEBP.
If approved, the MEBP office will contact the Employer and Employee with Effective Date and new payroll deduction.
IMPORTANT:
The beneficiary of the Optional Life Insurance will automatically be the same as the beneficiary of Basic Life Insurance unless otherwise indicated by the Member. Please refer to the Changes to Beneficiary – Basic and Optional Life section of this manual for additional information in this regard.
Optional Life coverage Applications or requested increases must receive approval by the Insurance Carrier. Therefore, please do not start deducting or change any contributions for Optional Life Coverage until you are advised to do so by MEBP Administration Office.
Changes to Insurance Coverage – Family Life
Have the Member complete the Blue Cross/MEBP Insurance Change form.
If the Member previously did not have Family Life Insurance, and now wishes to apply:
- The Member must be under age 65.
- Have the Member check off the "Type of Change" on top of the form.
- Complete Name and Address, Gender and Date of Birth.
- Under "Family Life Coverage", check off "ADD" and complete the requested section for eligible spouse and children's names, gender, birthdate, etc. For a definition of eligible Family Member, please refer to the Family Life Insurance – Eligible Family Member section of Part 2 – The New Employee – Enrolling Members section of this Manual.
- Marital Change area of the form must be completed.
- Employer section to be completed, signed and dated.
The original application must be forwarded to the MEBP Administration Office for approval. The MEBP Administration Office will inform the Employer and the Member of the deduction and Effective Date if approved by our Insurance Carrier.
This Insurance can be approved automatically if applied for within 31 days of acquiring a spouse or a child (if not in a marital relationship). The MEBP Administration Office will notify both the Employee and Employer in writing.
To cancel Family Life Insurance coverage:
- Have the Member check off the "Type of Change" on top of the form.
- Complete Name and Address, Gender and Date of Birth.
- Under "Family Life Coverage", check off "DELETE".
- Complete the Authorization of Change
- Employer section to be completed, signed and dated.
Deductions for Family Life contributions cease effective the "Date of Change" indicated by the Employer at the bottom of the form.
Changes to Beneficiary – Basic and Optional Life
Changing the Beneficiary only:
If the Member is only changing their Beneficiary and not changing anything else in regard to their Basic or Optional Life coverage(s), they can complete the BLUE CROSS/MEBP Group Life Insurance Beneficiary Designation Form. This form is available under FORMS – Blue Cross/MEBP Insurance Section on the MEBP website.
This Beneficiary Designation will be used for both the Basic Life and Optional Life Insurance (if applied for) unless otherwise indicated. If the Member wishes to have a separate designation for their Optional Life coverage, a separate BLUE CROSS/MEBP Group Life Insurance Beneficiary Designation Form for each plan (basic and optional) is required to be completed.
Changing the Beneficiary along with other information or coverage amounts changes to the Insurance Plan(s):
The change to beneficiary can be made directly on the Blue Cross/MEBP Insurance Change Form being completed by the Member along with other changes being made.
Important: The change to beneficiary designation will be used for both the Basic Life and Optional Life Insurance (if applied for) unless otherwise indicated.
If the Member wishes to have a separate designation for their Optional Life coverage, they are also required to complete a separate BLUE CROSS/MEBP Group Life Insurance Beneficiary Designation Form for the Optional Life Insurance beneficiary.
Changing the Beneficiary due to marital status change:
Have the Member complete the Blue Cross/MEBP Insurance Change form (MBCchange). Please have them indicate "The Type of Change" by checking off what has changed such as "Marital Status", and make any requests they may need due to this status change. These requests can include a new beneficiary designation, application/cancellation of Family Life coverage, etc. The "Date of Change" must be completed on the bottom of the form. This date is the date of the Marital Status Change. If making changes (other than beneficiary designation) the "Authorization of Change" must also be signed and dated by the Member.
Beneficiary's name has changed
If the beneficiary has a change of name, a BLUE CROSS/MEBP Group Life Insurance Beneficiary Designation Form or a Blue Cross/MEBP Insurance Change form can be completed correctly indicating the new beneficiary designation(s).
Changes to Information – Voluntary Accidental Death & Dismemberment
If a Member has coverage under Voluntary Accidental Death & Dismemberment Insurance, a new Application/Change - Voluntary AD&D Insurance (Form 78) is to be completed when any type of change is made. This form is available under FORMS – Employers section on the MEBP website. Indicate the changes being made by also completing the "Changes" section of the.
The following changes can be reported on this form:
- Name
- Change to Plan (Family or Employee)
- Change of Coverage amount
- Change to Beneficiary
- Coverage cancellation
The Member and witness must sign and date this form and all changes are effective of this date. The Member’s name and Initials are required on page two (2) of the form.
The original signed form should be sent to the MEBP Administration Office, a copy given to the Member and a copy can be kept on file. Change the payroll deductions accordingly.