Spousal Certification Form printable pdf download

Annual Eligibility Certification for Plan Year 2016

Spousal Certification (Primary Coverage)

Employees seeking primary coverage for a spouse shall certify spousal income to determine eligibility. Upon

verification, spousal eligibility is effective for the entire 2016 Plan year; provided there is no change in your

spouse’s eligibility. Refer to the Summary Plan Description and Plan Document for eligibility rules.

2016 Spousal Eligibility Levels

(Based on prior year’s annual adjusted gross income as documented on federal income tax return.)

Less than $26,700

Spouse can remain as primary, the spousal premium will not apply.

$26,700 to $58,400

Spouse can remain as primary, the spousal premium will apply.

Greater than $58,400

Spouse may remain as secondary at no additional cost. No primary coverage available.

Employee Name: ___________________________

Department: ______________________________

Spouse’s Name: ___________________________

Phone No.: ______________________________

Home

Work

Employees whose spouses are full-time permanent employees in a department covered under this insurance plan are exempt from

participating in this process (i.e., both employed by Wood County or both employed by Wood County Board of DD).

Employees whose spouses are part-time employees or in a department not covered under this insurance plan (Wood County/Wood

County Board of DD) must complete this form and document all sources of spousal income.

My Spouse works for Wood County. List Department/Office ________________________________

Full-time

Part-time

My Spouse works for Wood County Board of DD.

Full-time

Part-time

● To Elect Primary Coverage for a Spouse:

o Provide spousal income using the Spousal Income Verification form.

o Provide entire 2014 tax return, filed in 2015, including IRS 1040, W-2s for employee and spouse as

reported on IRS 1040, and all other applicable forms. (Requested tax information is utilized solely for

the purpose of determining spousal eligibility for insurance purposes and is forwarded confidentially to

an outside accountant for verification.)

o Place forms for Spousal Certification in a sealed envelope with name and department clearly marked on

the outside. (Do not include forms for Dependent Certification or other insurance forms.)

o Return sealed envelope to your Insurance Group Representative by within 30 days of the effective date

or Qualifying Event.

o Failure to provide the required information will result in the loss of spousal eligibility for primary

coverage until the next Open Election period or Qualifying Event.

Misrepresentation regarding eligibility of any covered individual may result in retroactive termination of coverage and collection of

paid claims, as well as disciplinary action and possible legal action as, and to, the extent permitted under applicable law.

All eligibility changes must be reported by completing and submitting a universal insurance application within 30 days of the

event/change.

I certify that the individual named above is my lawful spouse according to the Plan’s eligibility rules that define a Lawful Spouse as a

legally recognized marital partner of a covered employee, who is neither divorced nor legally separated from the employee.

Employee’s Signature ____________________________________________________________ Date ________________________

Spouse’s Signature ______________________________________________________________ Date ________________________

Q:\HR\INS\Eligibilty\Spousal\Spousal 16 Plan Year\Annual Forms\2016 Spousal Certification blank.docx

Spousal Certification Form

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