SPOUSE MEDICAL INSURANCE COVERAGE STATEMENT
St. Norbert College’s medical plan requires that an employee’s spouse enroll in at least single medical coverage through his/her employer to serve as their primary insurance coverage, or pay an additional surcharge to enroll in St. Norbert College’s medical plan as primary coverage. This additional surcharge is $50.00 twice per month ($1,200 annually).
All employees electing coverage for his/her spouse must complete the below statement. If your spouse is covered under the College’s medical plan currently and you do not return this coverage statement, you will be assessed the additional surcharge until St. Norbert College receives the proper notification from you.
Employee Name: ______Employee Social Security #: XXX-XX-______
(Please print)
Spouse Name: ______Spouse Social Security #: XXX-XX-______
(Please print)
My spouse is unemployed at this time. Date he/she became unemployed:______(No surcharge)
My spouse is retired. (No surcharge)
My spouse is self-employed and doesn’t offer group coverage to his/her employees. (No surcharge)
My spouse is a St. Norbert College employee. (No surcharge)
My spouse is employed but no health insurance is currently offered by his/her employer. (No surcharge)
Spouse’s Employer Name: ______
Address & Phone Number of the Employer: ______
My spouse has other medical insurance available through his/her employer but chooses primary coverage with St. Norbert College ($50.00 twice per month applies).
Spouse’s Employer Name: ______
Address & Phone Number of the Employer: ______
I hereby certify that the information contained on this form is true and correct. I understand that St. Norbert College reserves the right to verify the information provided on this form by contacting my spouse’s employer and that if my spouse becomes eligible for medical coverage from his/her employer during the plan year, I must notify St. Norbert College’s Human Resources of this change within 30 days. I also understand that intentional misrepresentation of any information constitutes fraud and is a serious violation of College policy, which may result in financial consequences and/or disciplinary action.
Employee Signature: ______Date: ______