COB 1 – Spouse Questionnaire

The Form

Form 1 – Spouse Questionnaire from the MPI website.

This form must be filled out by those who want to cover their spouse or same-sex domestic partner in the MPI Health Plan

This form declares current health plan coverage for you and your spouse. While the form asks for your current information, please understand that your participation in the MPI Health and Pension plans are contractually mandated. Participation in another plan does not keep you from participating in MPI. Also, MPI needs to be aware if your spouse is participating in another plan to properly coordinate the plans benefits.


* Click the image for a larger view but access the form using the link above.

In the top section of the form, under the first grey bar, you need to provide YOUR information. The section section, under the second grey bar, is where you fill out your spouse or partner’s information.

Be sure to sign and date the form before returning it to MPI.