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Is my dependent IRS Qualified?

In accordance with law, County benefits coverage can be provided on a tax-free basis to any eligible spouse or eligible child of the employee until the end of the month in which the child becomes ineligible for the County plans. If your eligible dependent is your own natural child, your stepchild, adopted child, child lawfully placed for adoption, or eligible foster child, you may indicate each as IRS Qualified regardless of the child’s marital or student status or whether or not the child is claimed as a dependent on your taxes.

Covered dependents who may not be eligible for tax-free health care (IRS Non-Qualified) may apply to your domestic partner and any children of your domestic partner (unless you have adopted the children), or dependents for whom you are the legal guardian. These individuals are not recognized as federal tax dependents, but are considered IRS Non-Qualified dependent(s), and the employee and employer contribution allocated to these dependents are considered a taxable benefit, and subject to Federal and State withholding, Social Security and Medicare taxes which will be deducted from your paycheck.

To review IRS Dependent Qualifications, please visit the IRS website.

Include all eligible dependents, including currently enrolled, being added and/or dropping.
If you have no dependents proceed to the next section.

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5

Dependent 6

Dependent 7

Dependent 8

Dependent 9

Dependent 10

Dependent 11

Dependent 12

Need to add more dependents? Please email Benefits at HR.Benefits@sonoma-county.org 

Information about Sonoma County Employee Medical Plans can be found on our website.

Need to find a PCP or look up a PCP number? Use the link below for your selected health plan provider. 
- Sutter Health - Find a Provider
- Western Health Advantage - Provider Search

Effective June 1, 2024
Employees
Employees will no longer be eligible to enroll in a County Health Plan (CHP) effective June 1, 2024. Employees enrolled prior to June 1, 2024 will be grandfathered into the plan. Once an employee leaves a CHP plan, they will no longer be eligible to return to a CHP plan.  

Extra help employees are not eligible to elect the County Health Plan.

Information about Sonoma County Employee Dental benefits can be found on our website.

County of Sonoma Employee Supplemental Life Insurance Enrollment/Change Form - Insured by UnitedHealthcare® 

Part-Time DSA, SCLEA and ESC Employees
Part-time regular DSA, SCLEA and ESC employees working less than 60 hours per pay period (.74 FTE or less) are eligible to purchase Basic and Supplemental Life Insurance. Basic Life Insurance rates are $0.028 per $1,000 in coverage. You must purchase Basic Life Insurance to be eligible to purchase Supplemental Life Insurance.

The County of Sonoma Supplemental Life Insurance Program allows eligible employees to purchase additional Life Insurance coverage as specified in their Memorandum of Understanding or Salary Resolution. If you qualify for and are enrolled in Basic Life Insurance you are eligible to apply for Supplemental Life Insurance. Your Basic Life and Supplemental Life coverage cannot exceed a combined $500,000. Please refer to the Employee Benefits webpage at https://sonomacounty.ca.gov/life-insurance for Basic and Supplemental Life insurance coverage information. Dependents are not eligible for Supplemental Life coverage.

Who can enroll?

You are eligible for Supplemental Life if you qualify for and are enrolled in Basic Life Insurance. Full or part time regular employees scheduled to work 60 or more hours per pay period (.75 FTE or greater) are automatically enrolled in Basic Life Insurance. Part-time DSA, SCLEA and ESC employees scheduled to work less than 60 hours per pay period may purchase Basic Life Insurance.

When can I enroll?

• Within 31 days of hire date or initial eligibility
• Annual Enrollment
• Within 31 days of a qualifying Mid-year Event (See Employee Benefits Guide for more information regardingMid-year Events)

When do I need to complete an Evidence of Insurability (EOI) form?
Newly Eligible: Supplemental Life insurance is automatically approved for an amount up to 3x your Basic Life coverage, referred to as a Guaranteed Issue amount. For any amount above 3x your Basic Life coverage, an EOI form will need to be submitted to UnitedHealthcare® (UHC) for approval.
Annual Enrollment and Mid-year Events: All new elections and increases require an EOI form be submitted to UHC for approval.

What will it cost me?
Supplemental Life insurance is employee paid with the cost based on your desired coverage amount and your age. If you elect coverage and are approved, the cost will be deducted from your paycheck. The current rates for each $10,000 in supplemental coverage are:

Age as of January 1st of current year

Ready to enroll?
Complete the below fields. Once submitted, save a copy for your records (download will be available on confirmation screen). Submittal of the Request for Enrollment is not a guarantee of enrollment. If needed, complete an EOI form and return to UHC for approval. Incomplete EOI forms could result in denial of your Supplemental Life Insurance application. You will be notified by UHC of their decision of your application.

County of Sonoma Employee Supplemental Life Insurance Enrollment/Change Form - Insured by UnitedHealthcare®

The County of Sonoma Supplemental Life Insurance Program allows eligible employees to purchase additional Life Insurance coverage as specified in their Memorandum of Understanding or Salary Resolution. If you qualify for and are enrolled in Basic Life Insurance you are eligible to apply for Supplemental Life Insurance. Your Basic Life and Supplemental Life coverage cannot exceed a combined $500,000. Please refer to the Employee Benefits webpage at https://sonomacounty.ca.gov/life-insurance for Basic and Supplemental Life insurance coverage information. Dependents are not eligible for Supplemental Life coverage.

Who can enroll?

You are eligible for Supplemental Life if you qualify for and are enrolled in Basic Life Insurance. Full or part time regular employees scheduled to work 60 or more hours per pay period (.75 FTE or greater) are automatically enrolled in Basic Life Insurance. 

Part-time regular DSA, SCLEA and ESC employees working less than 60 hours per pay period (.74 FTE or less) are eligible to purchase Basic and Supplemental Life Insurance. Basic Life Insurance rates are $0.028 per $1,000 in coverage. You must purchase Basic Life Insurance to be eligible to purchase Supplemental Life Insurance.

When can I enroll?

• Within 31 days of hire date or initial eligibility
• Annual Enrollment
• Within 31 days of a qualifying Mid-year Event (See Employee Benefits Guide for more information regardingMid-year Events)

When do I need to complete an Evidence of Insurability (EOI) form?
Newly Eligible: Supplemental Life insurance is automatically approved for an amount up to 3x your Basic Life coverage, referred to as a Guaranteed Issue amount. For any amount above 3x your Basic Life coverage, an EOI form will need to be submitted to UnitedHealthcare® (UHC) for approval.
Annual Enrollment and Mid-year Events: All new elections and increases require an EOI form be submitted to UHC for approval.

What will it cost me?
Supplemental Life insurance is employee paid with the cost based on your desired coverage amount and your age. If you elect coverage and are approved, the cost will be deducted from your paycheck. The current rates for each $10,000 in supplemental coverage are:

Age as of January 1st of current year

Part Time DSA, SCLEA, and ESC must select Basic Life and AD&D to be eligible for Supplemental Life

Part-time DSA, SCLEA and ESC employees scheduled to work less than 60 hours per pay period may purchase Basic Life Insurance.

Ready to enroll?
Complete the below fields. Once submitted, save a copy for your records (download will be available on confirmation screen). Submittal of the Request for Enrollment is not a guarantee of enrollment. If needed, complete an EOI form and return to UHC for approval. Incomplete EOI forms could result in denial of your Supplemental Life Insurance application. You will be notified by UHC of their decision of your application.

Ready to enroll?
Complete the below fields. Once submitted, save a copy for your records (download will be available on confirmation screen). Submittal of the Request for Enrollment is not a guarantee of enrollment. If needed, complete an EOI form and return to UHC for approval. Incomplete EOI forms could result in denial of your Supplemental Life Insurance application. You will be notified by UHC of their decision of your application.

Ready to enroll?
Complete the below fields. Once submitted, save a copy for your records (download will be available on confirmation screen). Submittal of the Request for Enrollment is not a guarantee of enrollment. If needed, complete an EOI form and return to UHC for approval. Incomplete EOI forms could result in denial of your Supplemental Life Insurance application. You will be notified by UHC of their decision of your application.

Ready to enroll?
Complete the below fields. Once submitted, save a copy for your records (download will be available on confirmation screen). Submittal of the Request for Enrollment is not a guarantee of enrollment. If needed, complete an EOI form and return to UHC for approval. Incomplete EOI forms could result in denial of your Supplemental Life Insurance application. You will be notified by UHC of their decision of your application.

Ready to enroll?
Complete the below fields. Once submitted, save a copy for your records (download will be available on confirmation screen). Submittal of the Request for Enrollment is not a guarantee of enrollment. If needed, complete an EOI form and return to UHC for approval. Incomplete EOI forms could result in denial of your Supplemental Life Insurance application. You will be notified by UHC of their decision of your application.

Ready to enroll?
Complete the below fields. Once submitted, save a copy for your records (download will be available on confirmation screen). Submittal of the Request for Enrollment is not a guarantee of enrollment. If needed, complete an EOI form and return to UHC for approval. Incomplete EOI forms could result in denial of your Supplemental Life Insurance application. You will be notified by UHC of their decision of your application.

Ready to enroll?
Complete the below fields. Once submitted, save a copy for your records (download will be available on confirmation screen). Submittal of the Request for Enrollment is not a guarantee of enrollment. If needed, complete an EOI form and return to UHC for approval. Incomplete EOI forms could result in denial of your Supplemental Life Insurance application. You will be notified by UHC of their decision of your application.

Part-time DSA, SCLEA and ESC employees scheduled to work less than 60 hours per pay period may purchase Basic Life Insurance.

Part-time DSA, SCLEA and ESC employees scheduled to work less than 60 hours per pay period may purchase Basic Life Insurance.

Part-time DSA, SCLEA and ESC employees scheduled to work less than 60 hours per pay period may purchase Basic Life Insurance.

You can view your current elections in ESS at https://ess.sonomacounty.ca.gov/selfServiceADF/faces/ssLogin

A primary beneficiary is a person(s) or entity that you designate to receive your life insurance benefits. If you are married, in the state of California, your spouse is entitled to 100% of the benefit. You can choose to leave some or all to another beneficiary(ies), provided you and your spouse complete the spousal consent form and have it notarized. If, and only if, your primary beneficiary(ies) have preceded you in death, the life insurance benefits will go to the contingent beneficiary(ies).

Beneficiary Designation / Spousal Consent Form 

You will need to complete and submit a Beneficiary Designation / Spousal Consent Form to complete this election. You will recieve an email with a copy of this form after submitting your benefit elections at the end of this process. You can also review and download a blank copy of the Beneficiary Designation / Spousal Consent Form here. 

Please note: this form requires both a hand written signature (no digital signatures will be accepted) and will need to be notarized before submission.  

Beneficiary Designation Form 

You will need to complete and submit a Beneficiary Designation Form. You will recieve an email with a copy of this form after submitting your benefit elections at the end of this process. You can also review and download a blank copy of the Beneficiary Designation Form here. 

Please note: this form requires a hand written signautre, no digital signatures will be accepted. 

Beneficiary Information is not reqired in this step and may be completed at a later time.

Primary Beneficiary 1

Primary Beneficiary 2

Primary Beneficiary 3

Contingent Beneficiary 1

Contingent Beneficiary 2

Contingent Beneficiary 3

Dependent Life Insurance covers each eligible dependent for $5,000; the employee is the beneficiary. The premium rate is $0.23 biweekly, which covers all eligible dependents including spouse/domestic partner and any dependent child, through the end of the month they turn age 26. Dependents employed through the County are not considered eligible dependents for dependent life. Eligible dependents can only be claimed by one employee.

IMPORTANT: You must be enrolled in Basic Life Insurance coverage in order to purchase Dependent Life Insurance. You will be required to show proof of dependent eligibility at the time a claim is made.

Mid-year events that allow new enrollment, termination and changes to FSA Dependent Care elections are limited. Please contact the HR Benefits Unit at benefits@sonoma-county.org if you believe you have an eligible life event and would like to enroll in, drop or make a change to your FSA Dependent Care election.

If you believe you have an eligible mid-year event and need to make a change to your FSA election(s), please email benefits@sonoma-county.org.

 Pre-Tax FSA Benefit Election

A Flexible Spending Account is an employee benefit that allows you to set aside pre-tax money from your paycheck to pay for healthcare and dependent care expenses.

Health Account FSA - Covers medical, dental and vision expenses that are only partially covered or not covered at all by your insurance, including insurance deductibles, insurance co-payments and over-the-counter medications.

Dependent Care Account FSA - Covers amounts you pay to daycare centers, after school programs, babysitters, caregivers or elder care so that you and your spouse can work.

1. A dependent under age 13;
2. A spouse who is physically or mentally unable to care for himself or herself; (c) A dependent who is unable to care for himself or herself and who qualifies as a dependent for income tax purposes

All eligible expenses must be incurred during the 2025 plan year, January 1, 2025 through December 31, 2025. Claims must be submitted for reimbursement no later than March 31, 2026. At the end of the plan year, eligible participants with remaining Health FSA funds may carry forward up to $660 of unused Health FSA funds. The carry forward funds can be used for eligible health expenses in the following plan year. Any unused funds in excess of $660 will be forfeited.

Health FSA Plan Annual Election Amount

Bi-weekly contribution is calculated by dividing the annual election amount by the remianing number of pay days in the calendar year. 

Annual Minimium: $130

Annual Maximum: $3,300

Dependent Care Assistance Plan

Bi-weekly contribution is calculated by dividing the annual election amount by the remianing number of pay days in the calendar year. 

Annual Minimium: $130

Annual Maximum: $5,000

Please review your elections carefully before submitting 
If you see items you want to change, you may navigate back using the sections at the top of the screen and make adjustments before submitting. Blank fields indicate no response provided.

Dependent(s)

*Only your applicable dependents will be listed, and any fields for which you did not provide a dependent will remain blank.
If you have no dependents, this entire section will be blank—please proceed to the next section.

Medical Plan

Coverage Level:  

Health Plan Provider: 
Plan Type: 

Employee PCP ID (if applicable): 

Dental Plan

Dental Election: 
Coverage Level: 

Supplemental Life

Election: 
Amount: 
 

Dependent Life

Dependent Life Election: 
 

Flexible Spending Accounts

Health Flexible pending Account Plan: 
Health FSA Annual Election Amount: 

Dependent Care Assistance Plan: 
Dependent Care Assistance Plan Annual Election Amount:  

County Health Plan Agreement: County Health Plan PPO or County Health Plan EPO

Anthem Blue Cross/Anthem Blue Cross Live and Health Insurance Company Arbitration Agreement

NON-PARTICIPATING PROVIDER: I understand that I am responsible for a greater portion of my medical costs when I use a nonparticipating provider.

REQUIREMENT FOR BINDING ARBITRATION ALL DISPUTES BETWEEN YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY, INCLUDING BUT NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN/POLICY OR ANY OTHER ISSUES RELATED TO THE PLAN/POLICY AND CLAIMS OF MEDICAL MALPRACTICE, MUST BE RESOLVED BY BINDING ARBITRATION, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT AND THE DISPUTE CAN BE SUBMITTED TO BINDING ARBITRATION UNDER APPLICABLE FEDERAL AND STATE LAW, INCLUDING BUT NOT LIMITED TO, THE PATIENT PROTECTION AND AFFORDABLE CARE ACT.

California Health and Safety Code Section 1363.1 and Insurance Code Section 10123.19 require specified disclosures in this regard, including the following notice: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as permitted and provided by federal and California law, including but not limited to, the Patient Protection and Affordable Care Act, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY AGREE TO BE BOUND BY THIS ARBITRATION PROVISION. YOU ACKNOWLEDGE THAT FOR DISPUTES THAT ARE SUBJECT TO ARBITRATION UNDER STATE OR FEDERAL LAW THE RIGHT TO A JURY TRIAL, THE RIGHT TO A BENCH TRIAL UNDER CALIFORNIA BUSINESS AND PROFESSIONS CODE SECTION 17200, AND/OR THE RIGHT TO ASSERT AND/OR PARTICIPATE IN A CLASS ACTION ARE ALL WAIVED BY YOU.

Enforcement of this arbitration clause, including the waiver of class actions, shall be determined under the Federal Arbitration Act (“FAA”), including the FAA’s preemptive effect on state law. By providing your electronic signature below, you acknowledge that such signature is valid and binding.

Kaiser Permanente Benefit Plan Agreement: Kaiser Permanente HMO, Kaiser Hospital Services Deductible DHMO, or Kaiser Deductible First HDHP

Kaiser Foundation Health Plan Arbitration Agreement

I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage.

Sutter Health Plus Member Agreement: Sutter Health Plus HMO ML42, Sutter Health Plus Hospital Services Deductible DHMO ML21, or Sutter Health Plus Deductible First HDHP HD01/HD51

BINDING ARBITRATION

Sutter Health Plus handles and resolves member disputes through grievance, appeal and independent medical review processes. However, in the event that a dispute is not resolved in those processes, Sutter Health Plus uses binding arbitration as the final method for resolving all such disputes.

As a condition of your membership in Sutter Health Plus, you agree that any and all disputes between yourself (including any heirs or assigns) and Sutter Health Plus, including claims of medical malpractice (that is as to whether any medical services rendered under the health plan were unnecessary or unauthorized or were improperly, negligently or incompetently rendered), except for small claims court cases and claims subject to ERISA, shall be determined by binding arbitration. Any such dispute will not be resolved by a lawsuit or resort to court process, except as California law provides for judicial review of arbitration proceedings. You and Sutter Health Plus, including any heirs or assigns to this Agreement, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration.

I hereby agree to give up my/our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Group Subscriber Contract and Evidence of Coverage and Disclosure Form.

Western Health Advantage Arbitration Agreement: Western Health Advantage HMO, Western Health Advantage Hospital Services DHMO, or Western Health Advantage Deductible First HDHP

By signing below, I acknowledge that I have read, understand and agree to the terms and arbitration agreement stated below. A reproduction of this form shall be valid as an original.

A. On behalf of myself and my eligible Dependents, I hereby apply for health care services coverage offered by Western Health Advantage (WHA) through my Employer, and agree to be bound by the WHA Group Service Agreement, Evidence of Coverage and Disclosure Form, and this Enrollment/Change Form.

B. ARBITRATION AGREEMENT: I AGREE AND UNDERSTAND THAT ANY AND ALL DISPUTES BETWEEN MYSELF (INCLUDING ANY HEIRS OR ASSIGNS) AND WESTERN HEALTH ADVANTAGE, INCLUDING CLAIMS OF MEDICAL MALPRACTICE (THAT IS AS TO WHETHER ANY MEDICAL SERVICES RENDERED UNDER THE HEALTH PLAN WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPETENTLY RENDERED), EXCEPT FOR SMALL CLAIMS COURT CASES AND CLAIMS SUBJECT TO ERISA, SHALL BE DETERMINED BY SUBMISSION TO BINDING ARBITRATION. ANY SUCH DISPUTE WILL NOT BE RESOLVED BY A LAWSUIT OR RESORT TO COURT PROCESS, EXCEPT AS CALIFORNIA LAW PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. THE PARTIES, INCLUDING ANY HEIRS OR ASSIGNS, TO THIS ARBITRATION AGREEMENT ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF BINDING ARBITRATION.

Waiver or Declination of Medical Plan Acknowledgment -You must complete this section if you are waiving or declining medical coverage for yourself and/or your eligible dependent(s).

If you wish to waive or decline coverage for yourself or your eligible dependents under County-offered medical plans, you must complete the information below. To waive medical coverage, the individual must have other group coverage or coverage through Covered CA, otherwise the election is to decline coverage rather than waive. Continuous coverage in other group insurance is a requirement for mid-year re-enrollment upon the loss of other group coverage or Covered CA.

By signing below, I acknowledge that I have been given the opportunity to enroll myself and my eligible dependents in a County-offered medical plan. I understand I will not be eligible to enroll in a County-offered medical plan until the plan’s next annual enrollment period or in accordance with the loss of eligibility for other group coverage or coverage through Covered CA. If I become eligible to make a change during the plan year, I must request enrollment within 31 days of the qualifying event.

Health FSA Plan

Health FSA Plan Annual Election Amount: 

Authorization and Agreement

I hereby elect the benefit(s) indicated above. I have read and understand the plan informational materials and I authorize the County of Sonoma to deduct the elected pre-tax Annual Election Amount during the plan year. Bi-weekly contributions withheld will be based on the Annual Election Amount and the number of pay periods remaining in the plan year. I understand that this election is binding and cannot be revoked or modified for the current plan year, except within 31 days of a qualifying change in family or work status event (e.g., marriage, divorce, birth). I further understand that any remaining funds that are not used for eligible expenses incurred during the Coverage Period, in excess of $660, will be forfeited in accordance with the current plan provisions and tax laws.

Dependent Care Assistance Plan 

Dependent Care Assistance Plan Annual Election Amount: 

Authorization and Agreement

I hereby elect the benefit(s) indicated above. I have read and understand the plan informational materials and I authorize the County of Sonoma to deduct the elected pre-tax Annual Election Amount during the plan year. Bi-weekly contributions withheld will be based on the Annual Election Amount and the number of pay periods remaining in the plan year. I understand that this election is binding and cannot be revoked or modified for the current plan year, except within 31 days of a qualifying change in family or work status event (e.g., marriage, divorce, birth). I further understand that any remaining funds that are not used for eligible expenses incurred during the Coverage Period, in excess of $660, will be forfeited in accordance with the current plan provisions and tax laws.

Health FSA Plan & Dependent Care Assistance Plan

Health FSA Plan Annual Election Amount: 

Dependent Care Assistance Plan Annual Election Amount: 

Authorization and Agreement

I hereby elect the benefit(s) indicated above. I have read and understand the plan informational materials and I authorize the County of Sonoma to deduct the elected pre-tax Annual Election Amount during the plan year. Bi-weekly contributions withheld will be based on the Annual Election Amount and the number of pay periods remaining in the plan year. I understand that this election is binding and cannot be revoked or modified for the current plan year, except within 31 days of a qualifying change in family or work status event (e.g., marriage, divorce, birth). I further understand that any remaining funds that are not used for eligible expenses incurred during the Coverage Period, in excess of $660, will be forfeited in accordance with the current plan provisions and tax laws.

Confirmation of Waived Elections

I certify that have reviewed my elections, and have elected to decline / waive the below benefit(s).

Employee Authorization and Signature

I hereby elect the benefit plan(s) designated on this form. I have also listed my eligible dependent(s) to be added to, or deleted from, the designated benefit plan(s). I also declare under penalty of perjury that all eligible dependents listed above meet the plans’ eligibility requirements and all eligible dependents listed as IRS Qualified dependents meet the IRC Section 152 definition of a qualified dependent.

I authorize my employer to deduct from my salary the amount required to cover my share of the premium payment (including any future premium increases). I agree for myself and my dependent(s), effective immediately and for as long as necessary to process claims:

• To be bound by the terms and conditions of the applicable Group Agreement as it may be amended
• To authorize providers who have rendered services to me and my dependent(s) to make health information and records regarding those services available to the health plan and their providers who, in turn, may share such records among themselves.
• To complete and submit consents, releases assignments, and other documents related to protecting the health plan’s rights under the Group Agreement. This includes coordinating benefits with other group health plans, insurance policies, Worker’s Compensation, or Medicare. I also agree to pay the cost incurred by the health plan out of any awards, settlements, or payments made to me in connection with personal injuries sustained by me or my dependent(s).
• I certify each Social Security number listed on this application is correct.

I understand that I must complete a new County of Sonoma Employee Benefits Enrollment/Change Form within 31 days of a change in this qualification or a change of benefit eligibility. I understand that the employee portion of the benefit premiums will be pre-tax only for IRS Qualified dependents. Further, I understand that I am responsible for the tax consequences (including interest and penalties) should there be any misstatement made on this declaration, or even in the absence of a misstatement, should the IRS or the State of California so determine that the benefits I am receiving for dependents listed as Qualified are found to be Non-Qualified.

I also certify that the information provided on this form is complete, true, and correct to the best of my knowledge.