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DocHub form-library379890-spousalGet Spousal Health Care Eligibility Affidavit - US Legal Forms 2026

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The document is a Spousal Healthcare Eligibility Affidavit for employees of Mohawk Industries, outlining the requirements for enrolling a spouse in the company's health care plan. It includes sections to determine the spouse's employment status and eligibility for medical coverage, as well as potential spousal surcharges based on their access to other health insurance. The affidavit requires signatures from both the employee and their spouse, along with employer verification if applicable.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Employee Name and Reference Number at the top of the form.
Fill in your Spouse's Name, Gender, and the last four digits of their Social Security Number.
Complete Section A based on your spouse's employment status. Check the appropriate box that applies to your spouse's situation regarding employment and health coverage.
If applicable, ensure Section B is filled out by your spouse’s employer if they are employed with access to medical coverage or self-employed.
Both you and your spouse must sign and date the affidavit at the bottom of the form to certify that all information provided is accurate.
Submit the completed document to Alight Solutions via fax or email as indicated in the instructions.

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Versions	Form popularity	Fillable & printable
2020	4.1 Satisfied (53 Votes)
2015	3.9 Satisfied (58 Votes)

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What is a spousal healthcare eligibility affidavit?

The Medical Plan Affidavit will require the spouse to indicate if they are employed. If the spouse is employed, the spouses employer will be required to complete the Medical Plan Affidavit to confirm that the spouse is not eligible for group medical coverage with their employer.