• Spousal Eligibility Verification

  • For spousal verification, other medical coverage includes employer-sponsored coverage, retiree coverage, and government-sponsored coverage, including Medicare and Medicaid.

    Do not proceed until you have each of the required documents listed above. Incomplete submissions will not be accepted. To ensure the security of your personal information, all documents must be submitted via this encrypted form. All fields are required.

  • Section 1 - Employee & Spouse Information

  • Format: (000) 000-0000.

  • Section 2 - Required Documentation

  • Is Your Spouse Currently Employed or Self-Employed?*
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  • Additional Information and Attestation

  • Should be Empty: