Spousal Coverage Verification Form printable pdf download

SPOUSAL COVERAGE VERIFICATION

WELFARE FUND BENEFITS OFFICE • UFCW LOCAL 655

13537 Barrett Parkway Dr., Ste 100 – Manchester, Missouri 63021 – (314) 835-2700 (in St. Louis) or (866) 565-2700 (outside St. Louis)- Fax (314) 966-9848

Participant Information

Name: ______________________________________________________________________________________________________

Last Name

First Name

Middle Initial

Policy Holder’s ID No.: __________________________________________________

Gender: □ Male □ Female

Address: ____________________________________________________________________________________________________

City: _____________________________________________ State: ________________ Zip Code: ___________________________

Phone Number: _____________________________________________

Birth Date: _____ / _____ / _____

Month

Day

Year

Marital Status

□ Single: Sign Certification of True Statement below.

□ Widowed: Sign Certification below. Date of spouse’s death _____ / _____ / _____

□ Married: Date of Marriage: _____ / _____ / _____ (Complete following question).

□ Divorced: Date of Divorce: _____ / _____ / _____

□ Legally Separated: Date of Separation: _____ / _____ / _____

Spouse Information

Name: ______________________________________________________________________ Gender: □ Male □ Female

Last Name

First Name

Middle Initial

Social Security Number: ____________________________________________________ Birth Date: _____ / _____ / _____

Month

Day

Year

Is your spouse employed?

□ Yes, and is enrolled in other medical coverage (complete section I below, III and V on reverse side of form)

□ Yes, and is NOT offered or enrolled in other medical coverage (complete section I below, III and IV on reverse side of form)

□ Self-Employed (complete bottom of form, and sections III and IV on reverse side of form)

□ No (complete bottom of form)

I. Certification of True Statement

I certify that all of the information contained on this form is accurate and complete to the best of my knowledge. If my spouse’s

employment situation changes, or they no longer qualify as a dependent under UFCW Local 655 Welfare Fund, I will contact the

Fund Office within 30 days. I hereby authorize my employer to release information regarding my employer’s health insurance plan

and my eligibility for coverage under that plan to the Fund. I understand this authorization remains in effect as long as I am eligible

for benefits under the Fund. I understand the purpose and scope of this authorization is to allow the Fund to verify with my employer

whether I am eligible to collect or obtain coverage under my employer’s health plan.

Participant’s Signature: __________________________________________________________ Date: ________________________

Spouse’s Signature: _____________________________________________________________ Date: ________________________

II. Certification

By signing below, I certify that my spouse is:

____ Not employed and not eligible for other coverage through an employer.

____ Self-employed and not offered any insurance through the self-employed arrangement (Complete sections III and IV

on reverse side of form).

I understand my signature under this portion of the form must be notarized with each yearly submission.

Participant’s Signature: _________________________________________________________________ Date: __________________

Notary Public’s Signature: ______________________________________________________________ Date: __________________

[Notary: Please affix seal to the upper right portion of this form.]

Spousal Coverage Verification Form

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