Annualspousal/Domestic Partner Certification Form

ANNUALSPOUSAL/DOMESTIC PARTNER CERTIFICATION FORM

An employee’s spouse/domestic partner is not eligible for coverage with UNITED CHURCH HOMES if he/she is employed by a company who offers medical plan benefits and is eligible for that coverage. . In order for a spouse/domestic partner to have medical coverage, the spouse/domestic partner must enroll in that employer’s medical insurance coverage.

If your spouse is not eligible by another employer’s medical insurance plan, you must update this formANNUALLY before he/she can continue to be covered under the UNITED CHURCH HOMES medical plan.

SECTION I

To Be Completed by UNITED CHURCH HOMES Employee & Spouse/Domestic Partner
I, ______(PRINT Employee Name), certify that my spouse/domestic partner:

Is not employed

Is retired and does not have health insurance through his/her former employer

Is self-employed and does not have health insurance

If A, B, or C applies, both the employee and spouse/domestic partner must sign the back of form.
You do not need to complete Section II.

Is employed and does not have group health insurance offered to him/her

Is employed part-time and is not eligible for his/her employer’s medical insurance

If D or E applies, both the employee and spouse/domestic partner must sign the back of form and
have spouse/domestic employer complete Section II.

SECTION II

To Be Completed by Spouse/Domestic Partner’sEmployer
Company Name:
Company Address:
1-______(PRINT Spouse/Domestic Partner Name) is eligible for insurance coverage with our
plan effective______(date).
2-______(PRINT Spouse/Domestic Partner Name) is not eligible for insurance coverage with our plan because ______.
Signature of HR Representative / Date / Telephone Number

I certify that the information on this form is true and correct. I understand that if my spouse/domestic partner has medical coverage available to him/ her through his/her employer, he/she is not eligible to be covered as a dependent on the UNITED CHURCH HOMES medical plan.

I agree that, in the event my spouse/domestic partner becomesbenefits eligible for coverage from an employer, I will advise UNITED CHURCH HOMESwithin seven (7) days of this change. Further, I am aware that falsification of information on this document or failure to advise of spousal/domestic partner employment may constitutes insurance fraud.Falsification of information may also lead to disciplinary action up to and including termination of employment.

EMPLOYEE SIGNATUREDATE

SPOUSE/DOMESTIC PARTNER SIGNATUREDATE

A new spousal/domestic spouse certification form is required

to be completed each year.

The completed form can be returned to L.R. Webber Associates, Inc.