EMPLOYEE SPOUSAL DEPENDENT ATTESTATION FORM

To be completed by ALL applicable employees who have a spouse enrolled in a Peak10 Benefit
Plan.
Instructions:
1.
2.
3.
4.
5.

Complete applicable information below

Attach most recent tax return (Form 1040) showing legal dependent status, or;
If married since last income tax filing, please attach a copy of your marriage certificate
Attach additional required documentation as referenced in this form
Return to mattison.richardson@peak10.com by May 16, 2016

Employee Name
1. ARE YOU LEGALLY MARRIED?
YES
(Continue to next step)

Location
NO (Sign and return to HR)

Spouses Name
2. IS YOUR SPOUSE EMPLOYED?
YES(Continue to question 3) NO (Sign and return to HR)
3. TO BE FILLED OUT BY SPOUSES EMPLOYER:
Spouses Employer Name
Spouses HR or Benefits Contact
Contact Phone Number
Is the above named employee eligible to
participate in their employers medical benefits
plan?

YES

NO

4. WHY IS YOUR SPOUSE NOT ENROLLED IN HIS/HER EMPLOYERS MEDICAL

BENEFITS PLAN?
My spouse is self-employed (provide proof - 1040, K-1, Schedule C)
My spouses employer doesnt offer medical insurance benefits
My spouse is not eligible for benefits with their employer
Peak 10 benefits are preferable to my spouses benefit offering (surcharge
applies)
My spouse is retired (if your spouse is retired, please complete the
information below)
Spouses Former Employer Name
Spouses Benefits Contact
Contact Phone Number
By signing below, I certify that the information provided above is correct and true. I further
understand that if the individual listed as my spousal dependent is eligible to participate in
their employers benefit plan that I will be responsible for paying the spousal surcharge of $75
per pay period from the beginning of the current plan year to present and going forward.
Additionally, I understand that if the individual listed as my spouse is found to not be my legal
dependent, they will be removed from the Peak 10 Benefits Plan and any claims paid on their
behalf will be denied.
Date
Employee signature:
: