Spouse/Domestic Partner Health Plan Eligibility Form – Human Resources

Required if an employee elects to cover a spouse or domestic partner on the College’s health, dental, or vision plan(s).

Spouse/Domestic Partner Coverage Rule * Required
Many family units include two working adults who each have access to a health, dental and/or vision plan partially paid for by their employer. Employers, including Kalamazoo College, take the approach that each employer should accept primary coverage responsibility for their own employees. An employed spouse or partner of a Kalamazoo College faculty or staff member who has health, dental, and/or vision insurance coverage available through his/her/their own employer, and that employer contributes at least 50% of the cost of coverage, may enroll as a dependent in Kalamazoo College’s health, dental, and/or vision plan(s) only if he/she/they is enrolled for primary coverage through his/her/their employer.
I understand and will comply.
Employee's Name * Required
First Last
Spouse/Domestic Partner's Name * Required
First Last
Is your spouse/domestic partner employed? * Required
- Yes
- No
What is the name of your spouse/domestic partner's employer? * Required
Does your spouse/domestic partner have group health coverage available through his/her/their employer? * Required
- Yes
- No
Does that employer pay at least fifty percent (50%) of the cost of coverage? * Required
- Yes
- No
Is your spouse/domestic partner enrolled in that coverage? * Required
- Yes
- No
Signature