Page 27 - CPS Benefits Guide
P. 27
SPOUSAL COVERAGE
Verification for Medical Coverage
Spouses of employees who have access to their employer sponsored medical plan must elect coverage through that employer’s
plan and are not eligible for the medical plan. This form is provided for you, the employee, to certify your spouse can either remain
on the plan because he/she meets the necessary criteria, or you acknowledge they do not meet the necessary criteria and they will
be removed from the plan.
□ My spouse works and is enrolled in his/her employer’s health plan
□ My spouse does not work or is self-employed
□ My spouse works for an employer who does not offer health coverage to their employees, or my spouse is not eligible to
participate in their employer’s health plan, or my spouse works and is offered health insurance through his/her employer;
however, his/her employer does not contribute towards the health plan
Your name (printed) Employee#
Your signature and date
Spouse employer name, address, and phone
Dependent Eligibility Terms and Conditions
Right to request documentation: CPS has the right to request documentation from an employee who declares their spouse is
not eligible for their employer’s health plan. In addition, we have the right to ask for tax records to prove non-working or self-
employment status.
Recourse for making a false statement: an employee who intentionally falsiies his/her spouse’s status on this form will be subject to
immediate repayment of premium paid by the company and may be released from employment or terminated from the beneit
plan for intentional falsiication of employment-related paperwork. Spouse will be terminated from coverage effective on the
date of ineligibility if form is determined to be falsiied or employee has failed to update Human Resources. You must update your
spouse’s status within 30 days from the date they become eligible for an employer sponsored health plan or you may be subject to
the terms and conditions of making a false statement. By signing this form you certify you have read and understand the terms and
conditions.
© 2016 Lockton, Inc. All rights reserved.
[Rev 03/28/16] EB\COMPH\EE Comm\Flyers\2016-17\Spousal Afidavit 16-17 3594.pdf
Comprehensive Pharmacy Services 27
Verification for Medical Coverage
Spouses of employees who have access to their employer sponsored medical plan must elect coverage through that employer’s
plan and are not eligible for the medical plan. This form is provided for you, the employee, to certify your spouse can either remain
on the plan because he/she meets the necessary criteria, or you acknowledge they do not meet the necessary criteria and they will
be removed from the plan.
□ My spouse works and is enrolled in his/her employer’s health plan
□ My spouse does not work or is self-employed
□ My spouse works for an employer who does not offer health coverage to their employees, or my spouse is not eligible to
participate in their employer’s health plan, or my spouse works and is offered health insurance through his/her employer;
however, his/her employer does not contribute towards the health plan
Your name (printed) Employee#
Your signature and date
Spouse employer name, address, and phone
Dependent Eligibility Terms and Conditions
Right to request documentation: CPS has the right to request documentation from an employee who declares their spouse is
not eligible for their employer’s health plan. In addition, we have the right to ask for tax records to prove non-working or self-
employment status.
Recourse for making a false statement: an employee who intentionally falsiies his/her spouse’s status on this form will be subject to
immediate repayment of premium paid by the company and may be released from employment or terminated from the beneit
plan for intentional falsiication of employment-related paperwork. Spouse will be terminated from coverage effective on the
date of ineligibility if form is determined to be falsiied or employee has failed to update Human Resources. You must update your
spouse’s status within 30 days from the date they become eligible for an employer sponsored health plan or you may be subject to
the terms and conditions of making a false statement. By signing this form you certify you have read and understand the terms and
conditions.
© 2016 Lockton, Inc. All rights reserved.
[Rev 03/28/16] EB\COMPH\EE Comm\Flyers\2016-17\Spousal Afidavit 16-17 3594.pdf
Comprehensive Pharmacy Services 27
