F200037 Headquarters – Life Event Reporting

F200037 Headquarters – Life Event Reporting

Instructions:

Welcome to the World Bank Group HR Forms Instructions page.

This form filler tool is designed to assist you in electronically entering your data and printing a paper form with a unique barcode corresponding to your entered data. Once you've completed your answers and printed the form, you'll need to submit it either by email or in person, depending on the form type.  Please note that the data you enter is directly captured in the form's unique barcode, so it's important that you do not make any handwritten changes, corrections, or additions to the data or to the form after it has been printed. Doing so may result in data errors and processing delays.

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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*