F200037 Headquarters – Life Event Reporting

F200037 Headquarters – Life Event Reporting

Instructions:

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Information on Completing the Form - Form must be completed electronically. If not, it will be rejected for processing

a.  Retiree & staff with no access to myHR self-service, use this form to report Birth/Marriage/Divorce/Legal Separation/Domestic Partnership registration or dissolution/Adoption.

b.  Reporting of life events must be made within 60 days from the life event date. For other scenarios it should be reported within 60 days from the end of active coverage date.

Note: For adding a new child to your medical coverage as a result of a birth or adoption, enrollment will be effective as of the birth/adoption date (retroactive premiums will be applied), so long as notice is provided within the first year of the event. All other supplemental insurance, dependent life insurance (if 1st eligible dependent) are not applicable if it is not reported within 60 days.

c.   If you do not request enrollment in the MIP /RMIP coverage within 60 days from end of active coverage and then later request enrollment in the MIP /RMIP coverage, you must provide evidence of coverage for three consecutive years, if applicable, by another medical insurance plan for the period immediately prior to requesting enrollment in MIP /RMIP coverage.

d.  For active staff, if you don’t opt to enroll into medical insurance now, you have a option to enroll during open enrollment.

e.  For enrollments requiring approval by HR Operations e.g. adoption, domestic partnership, supporting documentation that are not in English, an English translation must be provided. Please refer to the applicable checklist for the list of supporting documents.

f.  Save form after completing it electronically, ensure you sign and date it, and then send it to HR Operations (please use only one submittal method and submit once):
Fax +1 (202) 522-7026  or  via email:  hroperations@worldbank.org

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 25 Apr 2023

Retiree/Staff Information

World Bank Group UPI*

I am a*

First Name*

Middle Name

Last Name*

I am reporting (can select only one)*

Child Information

First Name*

Middle Name

Last Name*

Gender*

Birth Date*

Country of Birth*

City of Birth*

Country of Citizenship*

Would you like to add this child to your current medical plan?Refer Premium table*

Will this child be living at home and is dependent upon you for at least 50% of his/her financial support?*

Do you intend to increase your Life Insurance*

If this is your first eligible dependent, do you wish to enroll in  Optional Dependent Group Life Insurance?*

Child Information

First Name*

Middle Name

Last Name*

Gender*

Birth Date*

Country of Birth*

City of Birth*

Country of Citizenship*

Would you like to add this child to your current medical plan?Refer Premium table*

Will this child be living at home and is dependent upon you for at least 50% of his/her financial support?*

Do you intend to increase your Life Insurance by one time*

If this is your first eligible dependent, do you wish to enroll in  Optional Dependent Group Life Insurance?*

Domestic partnership Registration:

Domestic Partner Information

Staff Member Name*

Gender*

Domestic Partnership Name*

Gender*

Domestic Partner Birth Date*

Domestic Partner Nationality*

DP SSN (if exists)

US Visa Status

DP SSN (if exists)

US Visa Status*

If Others, specify*

Currently employed in any capacity by the International Monetary Fund*

(i) Is your spouse currently eligible for Expatriate Benefits from the IMF?*

(ii) Is your spouse going to receive dependency allowance from the IMF? (Please refer to Staff Rule 6.02 on coordination of benefits with the IMF)*

b. Did your spouse have prior income?*

Specify Income in USD*

Would you like to add your domestic partner to your current medical plan?*

Do you intend to increase your Life Insurance*

If this is your first eligible dependent, do you wish to enroll in Optional Dependent Group Life Insurance?*

Dissolution Information

Event Date*

Staff Member and Domestic Partner's information

First Name*

Middle Name

Last Name*

Domestic Partner’s Name

First Name*

Middle Name

Last Name*

Gender

Relationship

Event Date

City of Birth

Country of Birth

Would you like to add dependent children information*

Declaration

I certify that I will give my former domestic partner all - Medical Insurance Continuation information (MIP, MBP) so my former domestic partner may apply for Medical Insurance within the prescribed period of time (60 calendar days from end of Medical Insurance coverage). I further certify that I am responsible for reimbursing the World Bank Group for any Medical Insurance claims paid on behalf of my former domestic partner after the end of Medical Insurance coverage date for my former domestic partner. 

Birth :

Dependency Allowance for Dependent Children:

Child's Name

Nationality

Date of Birth

Gender

Visa Type

Dependent Questions

Would you like to add a child as a result of this event (Click on "ADD child" to add one child at a time)*

Are not related by blood to a degree that would bar marriage where we reside.*

Are not presently married or legally partnered to anyone else.*

Are each other's sole domestic partner and intend so indefinitely.*

Are legally competent to contract and of lawful age to marry.*

Have resided together in the same residence for at least 12 months or expect to meet the 12 month criteria by my appointment start date and intend to do so indefinitely.*

Have been jointly responsible to each other for basic living expenses and have joint financial commitment for at least 12 months or expect to have by my appointment start date and intend to do so indefinitely.*

Domestic partnership recognized by laws of your country.*

Supporting Documentation:

•   Domestic partner birth certificate or national ID or Passport page

•   Certificate of Domestic Partnership registration from national authorities if available

•   Proof of Cohabitation

•   Proof of joint Financial commitment

Birth :

Domestic partner Child / Child(ren)

Child's Name*

Nationality*

Date of Birth*

Gender*

Current Visa Type*

Would you like to add your Child to your current medical plan?*

Divorce/ Legal Separation

Spouse Information

First Name*

Middle Name

Last Name*

Gender*

Event Date*

Child information

First Name

Middle Name

Last Name

Gender

Relationship

Event Date

City of Birth

Would you like to add dependent children information*

Supporting Documentation:

Court ordered final divorce decree English translation, if the documents are not in English

Court issued legal separation English translation, if the documents are not in English

Adoption:

Child Information

First Name*

Middle Name

Last Name*

Gender*

Birth Date*

Country of Birth*

City of Birth*

Is child's age 13 or older?*

Is child sibling or half-sibling?*

Does the child belong to a category of relative, such as niece or newphew (Including relatives of domestic partner)?*

Will this child be living at home and is dependent upon you for at least 50% of his/her financial support?*

Would you like to add this child to your current medical plan?*

If this is your first eligible dependent, do you wish to enroll in Optional Dependent Group Life Insurance?*

First Name*

Middle Name

Last Name*

Gender*

Birth Date*

Country of Birth*

City of Birth*

Is child's age 13 or older?*

Is child sibling or half-sibling?*

Does the child belong to a category of relative, such as niece or newphew (Including relatives of domestic partner)?*

 Would you like to add this child to your current medical plan?*

Will this child be living at home and is dependent upon you for at least 50% of his/her financial support?*

Do you want to increase your optional life insurance by one level, if available?*

 If this is your first eligible dependent, do you wish to enroll in Optional Dependent Group Life Insurance?*

Do you want to increase your optional life insurance by one level, if available?*

If this is your first eligible dependent, do u wish to enroll in optional dependent Group Life Insurance?

Spouse Information

Spouse First Name*

Spouse Middle Name

Spouse Last Name*

Gender*

Birth Date*

Country of Birth*

City of Birth*

Country of Citizenship*

US Visa Status*

If Others, specify*

Is your spouse had worldwide income for the pervious calendar year?*

a. Currently employed in any capacity by the International Monetary Fund:*

(i) Is your spouse currently eligible for Expatriate Benefits from the IMF?*

(ii) Is your spouse going to receive dependency allowance from the IMF? (Please refer to Staff Rule 6.02 on coordination of benefits with the IMF)*

b. Did your spouse have prior income?*

Specify income in USD*

Would you like to add your spouse to your current medical plan?*

Would you like to increase your life insurance due to this life event?*

If this is your first eligible dependent, do you wish to enroll in Optional Dependent Group Life Insurance?*

Would you like to report your step child due to this Life event?*

Would you like to add your step child to your current medical plan?

Supporting Documentation:

• Marriage: Gov’t-issued Marriage certificate or alternative government issued document proving relationship to spouse

• Gov't issued ID proving spouse's date of birth and nationality, example: passport, birth certificate, national ID If reporting a stepchild as part of this request • Hospital record confirming birth and relationship or government issued birth certificate and Document confirming custody of the child and Document confirming that the child is residing in your household

Step Child Information(s)

First Name*

Middle Name

Last Name*

UPI*

Relationship

Gender

Birth Date

City of Birth

Country of Birth

Nationality

Enroll in MBP?

For Children Only:

Is child under age 26?

Step Child Information

First Name*

Middle Name

Last Name*

Gender*

Birth Date*

City of Birth*

Country of Birth*

Is Child under 26?*

Will this child be living at home and is dependent upon you for at least 50% of his/her financial support?*

Would you like to add this child to your current medical plan?*

Will this child be living at your home?*

Dependent Children

First Name*

Middle Name

Last Name*

The child is still a dependent*

I will continue to provide at least 50% of financial support*

The child resides in my household at my duty station*

Would you like to continue MIP/ RMIP coverage if the respective child is already covered ?*

Certificate & Signature

I confirm that I must update my Form 70 (Tax Allowance Certificate) via myHR Self-Service, if applicable, after receipt of the confirmation that the request has been completed. For any questions on the Form 70, please contact the Tax Office at taxoffice@worldbank.org or 202-458-4191.*

I understand that if the notification of this life event is after 60 days from the date of the event, the next opportunity to enroll my dependent to my medical insurance will be during the Open Enrollment Season.*

I understand that if the notification of this life event is after 1 year from the date of the event, the next opportunity to enroll my dependent to my medical insurance will be during the Open Enrollment Season.*

I confirm that supporting documentation has to be submitted for the primary nationality selected.*

I confirm that I may review and update my Insurance Beneficiary Designation after I receive confirmation that this request has been completed. Active staff to update via myHR Self-Service;  Retirees via F200054.*

I certify that the information I have provided is accurate and true.  Furthermore, I understand that reporting a life event impacts my household benefits as a World Bank Group staff member (e.g. Medical/Life Insurance, etc.), which can be subject to an audit. I understand that any misstatements may result in disciplinary measures per Staff Rule 3.00.*

I understand Staff Rule 2.01 allows automatic access to benefits, salary and pension information by a spouse or domestic partner.*

I certify that I will give my former spouse all Medical Insurance Continuation information (MIP) so my former spouse may apply for Medical Insurance within the prescribed period of time (60 calendar days from end of Medical Insurance coverage). I further certify that I am responsible for reimbursing the World Bank Group for any Medical Insurance claims paid on behalf of my former spouse after the end of Medical Insurance coverage date for my former spouse.*

I understand a former spouse or same-sex domestic partner G visa expires on the date of divorce or domestic partnership dissolution, regardless of the date stamped on the G visa or I-94 form.  U.S. Citizen and Immigrant Services, through the State Department, allows a 30-day grace period for my ex-domestic partner to take care of personal matters and depart from the U.S.*

I make and file this statement of Termination in order to Cancel my affidavit of Domestic Partnership on file with the World bank Group. *

I understand that after a domestic partnership is terminated, a subsequent affidavit of Domestic Partnership cannot be filed with the World bank Group until at least 12 months after the statement of Termination.*

I certify that I will give my former domestic partner all - Medical Insurance Continuation information (MIP, MBP) so my former domestic partner may apply for Medical Insurance within the prescribed period of time (60 calendar days from end of Medical Insurance coverage). I further certify that I am responsible for reimbursing the World Bank Group for any Medical Insurance claims paid on behalf of my former domestic partner after the end of Medical Insurance coverage date for my former domestic partner. 

Signature

Date

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.