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DocHub form-library379890-spousalGet Spousal Health Care Eligibility Affidavit - US Legal Forms 2026
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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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This Affidavit MUST be completed for consideration to cover a spouse. contact HR @ (678)625-1212
1. Employee must complete Section A of this form. 2. If your spouse is employed, he/she and their employer must complete Section B onRead more