Address Change Form 

Use this form if you’ve had a recent change to your home or mailing address. It’s important to notify HR promptly, as your new address may impact your benefit eligibility—particularly if you move outside of your current provider’s service area.

HR will review your address change and contact you if any action is needed regarding your benefits. This form will also be used to update your information in Tyler Munis, CalPERS, and with any other relevant benefit providers.

Name Change Form (Self or Dependent) 

Use this form if you or a covered dependent have legally changed their name. It’s important to notify HR as soon as the name change is finalized so we can ensure your records are accurate and up to date across all systems.

Proof of name change is required:

• For employees: A copy of your updated Social Security card is required.

• For dependents: Acceptable documents include a marriage certificate, court-issued name change document, or Social Security card reflecting the new name.

As a result of a name change for yourself, you will also need to complete updated versions of the following documents:

• Personal Data Sheet

• Designation of Warrants

• CalPERS Lump Sum Beneficiary Form

• CalPERS Special Power of Attorney Publication and Form

• Life Insurance Beneficiary Designation

As a result of a name change for a dependent, you may need to update the designation of warrants form or any beneficiary forms if they are currently listed under their previous name. You may also need to log in to your deferred compensation account to update your beneficiaries. 

Birth/Adoption/Foster Child Form

Use this form if you are adding a new child to your household due to birth, adoption, or placement for foster care. This Qualifying Life Event allows you to update your benefit elections and add your child to your medical, dental, and/or vision plans. For a summary of each plan's benefits and current premium rates, please review the Benefits Guide. 

Required documentation includes:

• Birth certificate or proof of live birth document for newborns

• Adoption papers/birth certificate for adopted children

• Court or placement documents for foster children

This form must be submitted within 30 days of the event. Late submissions may result in needing to wait until the next Open Enrollment period to make changes.

You may also wish to update your beneficiary designations (such as for life insurance or retirement) to include your new child.

• Designation of Warrants

• Life Insurance Beneficiary Form

• CalPERS Lump Sum Beneficiary Form

• American Fidelity Beneficiary Form (If currently enrolled in benefits)

• Log into deferred compensation provider to update beneficiaries

Marriage or Domestic Partnership Form 

Use this form if you’ve recently gotten married or entered into a registered domestic partnership. This Qualifying Life Event allows you to add your spouse or domestic partner—and any newly eligible dependents—to your benefit plans, such as medical, dental, and vision.

Required documentation includes:

• Marriage certificate

• State registration or City of Fairfield Notarized Affidavit for a domestic partnership

This form must be submitted within 30 days of the event. Late submissions may result in needing to wait until the next Open Enrollment period to make changes.

Important: Entering into a marriage or registered domestic partnership automatically voids all previously submitted beneficiary designations. To ensure your benefits are properly assigned, you must complete and submit updated versions of the following forms:

• Life Insurance Beneficiary Form

• Designation of Warrants

• CalPERS Lump Sum Beneficiary Form

• CalPERS Special Power of Attorney Publication and Form

• American Fidelity Beneficiary Form (if currently enrolled in benefits)

• Log in to your Deferred Compensation provider and update your beneficiaries

Divorce/Annulment/Termination of Domestic Partnership Form 

Use this form if you have recently finalized a divorce, annulment, or termination of a registered domestic partnership. You are required to remove your former spouse or domestic partner—and any dependents who are no longer eligible—from your benefit plans. For a summary of each plan's benefits and current premium rates, please review the Benefits Guide. 

Required documentation includes:

• Final judgment of divorce or annulment

• Termination of Domestic Partnership documentation filed with the state or a notarized City of Fairfield Termination of Domestic Partnership form 

This form and supporting documents must be submitted within 30 days of the event date.

Failure to notify HR within the 30-day window may result in you being financially responsible for premiums paid on behalf of ineligible dependents.

Important: A divorce or termination of domestic partnership automatically voids all previously submitted beneficiary designations. To ensure your benefits are assigned according to your current wishes, you must complete and submit updated versions of the following forms:

• Life Insurance Beneficiary Form

• Designation of Warrants

• CalPERS Lump Sum Beneficiary Form

• CalPERS Special Power of Attorney Publication and Form

• American Fidelity Beneficiary Change Form (If currently enrolled in benefits)

• Log in to Deferred Compensation account and update beneficiaries

Loss of Other Coverage Form or Gained Other Coverage Form 

Use this form if you or your dependent(s) have experienced a loss or gain of other health coverage, such as through a spouse’s employer or another group plan. This Qualifying Life Event allows you to enroll in, drop, or make changes to your benefit elections based on your new coverage status.

Required documentation includes:

• Loss of coverage: Letter from the previous insurance provider or employer indicating the names of who is losing coverage, type of coverage terminating, coverage end date and reason for termination

• Gain of coverage: Proof of enrollment in the new plan, including names of who is gaining coverage, type of coverage being gained, and the effective date of coverage

This form must be submitted within 30 days of the coverage change.

Failure to submit your request within the 30 days will result in having to wait until open enrollment to make changes. 

FTE Change Form (part-time to full-time or full-time to part-time) 

Use this form if you have experienced a change in employment status that affects your eligibility or affordability of benefits—for example, moving from part-time to full-time (now eligible for greater employer-paid contributions) or from full-time to part-time (reduced employer contribution, increased out-of-pocket cost).

For a summary of each plan's benefits and current premium rates for Full-Time employees, please review the Benefits Guide. 

For a summary of each plan's benefits and current premiums rates for Part-Time employees, please review the Pro-Rata Benefits Guide.

This Qualifying Life Event allows you to enroll in, drop, or make changes to your benefit elections based on your new benefit-eligible status.

Required documentation includes:

• Confirmation of the effective date of your status change from your department

This form must be submitted within 30 days of the change in status.

Failure to notify HR within the 30-day window may result in needing to wait until the next Open Enrollment period to make changes and may result in financial responsibility for premiums associated with unwanted coverage.

Please contact Human Resources if one of your previously ineligible dependents has regained eligibility for benefits. Common examples include:

• A dependent under age 26 who has moved back to the provider service area (e.g., returned from college)

• An over-age dependent who is/has become disabled and now qualifies for continued coverage

This QLE allows you to re-enroll the eligible dependent in your benefit plans (medical, dental, vision, etc.).

Depending on the reason, required documentation may include:

• Proof of date of return/relocation

• Physician certification and supporting documentation for newly disabled dependents

• Any additional documentation requested by specific benefit providers

Supporting documentation must be submitted within 30 days of the dependent regaining eligibility.

Failure to notify HR within this timeframe may result in needing to wait until the next Open Enrollment period.

We understand that experiencing the loss of a dependent is an incredibly difficult and emotional time. Please contact HR directly so we can personally guide you through the necessary steps and offer support during this time.

HR will assist you with updating your records with any relevant benefit providers. We will handle these updates with care and respect.

Please note: The loss of a dependent may also impact your beneficiary designations. If your dependent was previously listed as a beneficiary, you will need to complete new forms to ensure your records remain accurate:

• Life Insurance Beneficiary Form

• Designation of Warrants

• CalPERS Lump Sum Beneficiary Form

• CalPERS Special Power of Attorney Publication and Form

Our team is here to support you through every step. Please don’t hesitate to contact us with any questions or to begin the process.