Form Gg-015024-A - Dependent Eligibility Certification printable pdf download

Dependent Eligibility Certification Form

General Information

Member Name:

Individual Plan #:

Dependent Name:

Dependent Date of Birth:

Member Address:

Member ID #: _______________________________

Student & Dependent Certification

1. Is the child a dependent for tax purposes pursuant to the Internal Revenue Code? ___ YES ___ NO

2. If “NO”, in what tax year did you last claim the child as a dependent on your federal tax return? _____

3. Is the child a full-time student at an accredited school? ___ YES ___ NO

4. If “YES”, name and address of school in which dependent is enrolled: _________________________

_________________________________________________________________________________

5. Expected date of graduation (if this year): ____ /____ /____

DAY YR

Disability Certification

1. Is dependent now incapable of self-support because of a disability? ___ YES ___ NO

2. Age of dependent when disability occurred: ______

3. Nature of disability (Please provide as much detail as possible):

___________________________________________________________________________________

4. Prognosis (estimate months or years): _______________________

5. Name and address of Primary Care Physician: ___________________________________________

_________________________________________________________________________________

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND

AUTHORIZE RELEASE OF ANY INFORMATION REQUEST IN REGARD TO THE CERTIFICATION.

_________________________________________________________

_____________________

Member Signature

Date Signed

Any person who includes any false or misleading information on an application for insurance commits a fraudulent

insurance act and is subject to criminal and civil penalties.

Please complete this form and return it in the envelope provided to the following:

The Guardian Life Insurance Company of America, P. O. Box

254888 Sacramento CA 95865

GG-015024-A

(6/16)

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004.

GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.

Form Gg-015024-A - Dependent Eligibility Certification

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