COB 4 – Spouse Coverage Confirmation

The Form

Form 4 – Spouse Health Coverage Confirmation 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 is to to declare your spouse or same-sex domestic partner’s health coverage through their employer. This form also asks your spouse/partner to declare if any dependent children are covered under their plan.


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

In the first three lines of the form, your spouse/partner’s employer information should be provided. Next, your spouse/partner needs to indicate if they have or have not enrolled in their employer’s offered health coverage. If they did not enroll in their employer’s offered health coverage, the reason needs to be provided in the section on the far-right.

In the next section, information about your spouse/partner’s employer insurance should be provided. If your spouse/partner covered your dependent children under their plan, that needs to be properly indicated in the checkbox question and then the childrens information provided in the space below.

Finally, both you and your spouse/partner need to sign and date the form, as well as provide a contact telephone number, at the bottom of the sheet.