Ptucan ure LIFE Declaration of Co-habitational Relationship (EMPLOYERS NAME) | CONABITANTS'S NAMIE) (ADDRESS) Sincerely and slender hat we: 1. have been solely and continuous cohabiting as man and wife on bons fe domestic 2, Share a dove, prtona and exasveFlionship and are responsible foreach eters common welfare 3. share thesameregur and permanent resene with th tent to contnue dang dein ‘hav ech made Substantial Contributions tothe hoe ad amy constted by ou eb abatlona rlatioship 5 acknowiedge thatthe decorations mage here ae ap caret nd shall be uted forthe ppt of determing lity for insurance coverage and insurance bereft, and hat an person who knowing an wh intent otras By surance company x she ron fer statement containing any materiale nformaton or wth intent Ila conceals information concerning an fact mateal thereto, cmt Faudlent at andi abe to proseeton issn the month of ‘Employee's Signature ‘Cohabiants Signature [ DedaredBeforeme, Name: Ties OFFICIAL STAMP. this_ day, Inthe year___at. Sienature This setion is tobe competed by a Commissioner of Affidavits, lustc of the Peace, Notary Publ. NOTE: Tob ale fa erlnent ints Pan-Anera fe Group Plan the Cosa ofthe Epos Primary red MUST coating ‘thsi ployer Pinar sro inn on yao prensa pon upon ent ro sronert nor Pye ‘tan sree bent, Ol one pee dopendent tba ented stir, sisal Contin sea cd) at et ‘ian onto the decarnt’propery ot nan recor, (0) conten ar hamemalre Patent tothe ele ‘oy cotter