Spouse Affidavit

This form must be completed in full. A medical enrollment form is required if you are newly enrolling a spouse in Seiler Instrument’s Employer Provided Health Insurance Plan. If this form is not returned and you intend to enroll your spouse, Seiler Instrument will assume that your spouse is eligible for coverage through their employer, and the surcharge will apply.

This field is for validation purposes and should be left unchanged.

Employee Name(Required)

First Last

Spouse Name(Required)

First Last

Status(Required)

Please check the appropriate box.

My spouse is not actively working or is self-employed. (No surcharge will apply.)

My spouse is actively working but is not offered medical insurance coverage. (No surcharge will apply.)

My spouse is actively working, has declined coverage through his/her employer, and is enrolling in the Seiler Instrument Group Health Plan. I understand that I will incur the surcharge of the spouse’s portion of the premium ($70 per week).

Spouse Employer(Required)

Only reqired if spouse is working but is not offered medical insurance coverage.

By signing below, I confirm that all information provided is accurate, current, and complete to the best of my knowledge. I understand that falsifying information regarding my spouse’s available coverage may result in retroactive surcharge assessments and possible termination from the Seiler Group Health Plan. Willful provision of false information may lead to disciplinary action, including termination. I also understand that it is my responsibility to notify the Human Resources Department within thirty (30) days if my spouse’s coverage status changes.

Signature