Members with covered college-student dependents who are under the maximum dependent coverage age must submit a Student Coverage Questionnaire by December each year to ensure their dependents’ continued health benefits.
For college student dependents under the maximum coverage age to retain coverage, Empire requires that the dependent attend an accredited school of higher learning full-time, and that the employee contract holder submit the Student Coverage Questionnaire by December 31 of each year to establish continued enrollment. Members should be sure to check their benefit books to confirm over-age dependent eligibility terms.
The employee contract holder is responsible for completing the questionnaire and certifying that the information they are reporting is correct. The form requires, in addition to basic information:
the name and address of the educational institution
type of institution, and
expected date of the student’s graduation or completion
Completed and signed forms should be faxed or mailed to the following:
FAX to:
1-800-780-1224
MAIL to:
Empire
PO Box 1407
Church Street Station
New York, NY 10008-1407
