SPOUSE OR DOMESTIC PARTNER (DP) HEALTHCARE:
2024 SURCHARGE VERIFICATION FORM
The WMCHealth Plan provides you with the ability to enroll your spouse or DP in health benefits by paying pre-tax premiums or after-tax premiums if enrolling a DP. If your spouse or DP has medical coverage available with another employer, you can still enroll them in the WMCHealth Plan by paying an additional surcharge is applicable. If your spouse or DP is not employed, or is employed at a WMCHealth entity, or does not have medical coverage available with another employer, then no surcharge applies and the regular bi-weekly premiums apply. Please complete this form to verify that the surcharge does not apply.
If you do not complete this form, premiums to enroll your spouse/DP will default to include the surcharge.
SITUATIONS WHERE THE SURCHARGE DOES NOT APPLY
Please make your selection below if it applies to you, and provide information requested (if any) and sign in the e-signature box below.
My spouse/DP is
currently
not
employed
and does not have access to another employer's health coverage.
My spouse/DP is working at WMCHealth.
My spouse/DP is currently employed by another employer and
I certify that no medical coverage is offered to my spouse/DP
. Since no medical coverage is offered by another employer, no surcharge applies.
My spouse/DP is working at WMCHealth at the following entity:
Please select...
Westchester Medical Center
Advanced Physician Services
NorthEast Provider Solutions
MidHudson Valley Staffco
HealthAlliance
Bon Secours Charity Health System
BELOW IS THE EMPLOYER OF MY SPOUSE/DP:
Name of Spouse/DP's Employer:
Address of Employer:
Phone Number of Employer:
ATTESTATION & E-SIGNATURE
If your spouse/DP has coverage through another employer plan, you can still enroll you spouse/DP in the WMCHealth Plan and pay an additional surcharge in 2024. If your spouse/DP does not have medical coverage available elsewhere and you have certified this by completing and signing this form, no surcharge applies in 2024. WMC reserves the right to verify the above.
If my spouse/DP's status changes, I will notify the Total Rewards Office of this change within 30 days. By signing below, I am verifying the above information for purposes of enrolling my spouse/DP in the plan and not paying the spouse/DP surcharge.
I understand that my electronic signature below has the same force and effect as my written signature.
Employee First Name:
Employee Last Name:
Employee ID #:
6 digit code above barcode on employee ID