The system will prompt you to complete information for the employee/retiree, spouse and child with ongoing health insurance coverage provided by the employer of the employee/retiree. Use the following definitions to determine who is considered the Employee/Retiree, the Spouse and the Child:

Employee/Retiree: The individual who worked for an employer that is providing ongoing health insurance coverage for the employee/retiree and family.

Spouse: The individual who is married to the employee/retiree and has continuing health care coverage through the employee/retiree's employer.

Child: The "adult child" - including an adopted child, or, in some cases, a stepchild, grandchild, or step-grandchild - must be unmarried, age 18 or older, and have a disability that started before age 22 and is still covered under the employee/retiree's health insurance plan through his/her employer.

Important Information:

• The process may take up to 30 minutes, depending on the speed of your internet connection.
• You must respond to all questions with a red asterisk (*). The system will not allow you to proceed and will display an error informing you of the required questions that have not been answered.
• Use your "Tab" key to go to the next question on that page.
• Use the "Previous" and "Next" buttons to scroll between pages. Using the "Back" button may cause the information entered to be lost.
• When the system informs you that the questionnaire has been successfully completed, you must select the "Submit" button to send your answers for processing. Note: If you exit before you select the "Submit" button, all information you have entered will be lost.
• When you select "Submit", wait for a "Thank You" page.
• When the "Thank You" page is displayed your questionnaire has been submitted for processing. Click the "Completed" button to log out and exit the system.
• If you supplied your email address, you will receive an email with the results from your questionnaire.
• After 2 business days you can review the results from your questionnaire via the website.
• If you do not enter any information for a 30 minute period, the system will assume you are no longer on and will log you out. All information you have entered will be lost.
• If you need assistance in completing the form online please click on the "Contact Us" button on the "Welcome" page.

System Requirements    Preparation