Spouse Eligibility Verification Form printable pdf download

Spouse Eligibility Verification Form

SPOUSE ELIGIBILITY VERIFICATION FORM

In order to enroll an eligible spouse in the

Entity Name’s

group health plan, this

form must be filled out to verify other coverage.

I. Employee Information

SECTION A:

Employee Information

Name: __________________

______

Social Security Number:

________

________________________

II. Spouse Coverage Verification

A spouse must first be enrolled in any available employer‐sponsored group health

plan. This form must be completed if you are applying for spouse coverage. If your

spouse is self‐employed, the employer is his/her company. If your spouse is

unemployed or retired, you do not need to complete SECTION B of this form, proceed

to the Acknowledgement page; sign, date and return to your employer.

 Is your spouse employed?

Yes

 Is your spouse self‐employed?

Yes

 Is your spouse retired?

Yes

SECTION A:

Spouse Information

Name:

__________________

_____

Social Security Number:

________

_______________________

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TAC HEBP Spouse Eligibility Verification Form

Revised 6/2013

Spouse Eligibility Verification Form