Domestic Partner Form Western Health Advantage

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Non-Registered Domestic Partner Form
This form is used for employer groups that have agreed to cover non-registered domestic
partners as dependents. Employees wishing to enroll an unregistered domestic partner as a
dependent must complete this form in addition to submitting an Enrollment/Change form.
Generally, non-registered domestic partners that may be eligible to enroll as dependents are two
unmarried adults who have chosen to share one another’s lives in an intimate and committed
relationship of mutual caring but are not eligible for registration as domestic partners under
California law.
The undersigned Employee and Domestic Partner hereby attest that all of the following are true, and further
promise to notify WHA immediately if any of the following cease to be true:
1.
Both persons have a common residence.
2.
Both persons agree to be jointly responsible for each other’s basic living expenses incurred during the
domestic partnership.
3.
Neither person is married or a member of another domestic partnership.
4.
The two persons are not related by blood in a way that would prevent them from being married to each
other in this state.
5.
Both persons are at least 18 years of age.
6.
Either A or B:
A.
One or both of the persons meet the eligibility criteria under Title II of the Social Security Act as
defi ned in 42 U.S.C. Section 402 (a) for old-age insurance benefi ts or Title XVI of the Social Security Act
as defi ned in 42 U.S.C. Section 1381 for aged individuals.
B.
The persons do not meet the eligibility criteria under A above but the Subscriber’s employer has
approved eligibility of non-registered domestic partners.
7.
Both persons are capable of consenting to the domestic partnership.
8.
Neither person has previously fi led a Declaration of Domestic Partnership with the Secretary of State
pursuant to this division that has not been terminated under Section 299.
Employer Group
________________________________________________________________
Employee Name
________________________________________________________________
Signature
________________________________________
Date _______________
Domestic Partner Name ________________________________________________________________
Signature
________________________________________
Date _______________
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WHA 218 1/09

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