Clean harbors working spouse domestic partner medical provision form 2025

1. Click ‘Get Form’ to open the Clean Harbors Working Spouse/Domestic Partner Provision Form in the editor.
2. Begin by filling out Section 1, which requires your name, employee ID, and contact information. Ensure that you accurately indicate whether your spouse/domestic partner is currently employed and if they have access to a qualified ERISA Medical plan.
3. If your spouse/domestic partner is employed, provide their employer's details including name and contact information. If not, simply sign and date this section.
4. In Section 2, if applicable, have your spouse/domestic partner’s employer complete the verification regarding their eligibility for ERISA group medical coverage.
5. Review all entries for accuracy before signing and dating the form. Once completed, save your document.
6. Submit the form via fax or mail as instructed in the document to ensure timely processing of your spouse/domestic partner's eligibility.

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