Get the free Spousal Surcharge Form - West Tennessee Healthcare
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Spousal Surcharge Form
Employees who choose to cover their spouse on a West Tennessee Healthcare medical plan when the spouse has access to medical
coverage available through his/her employer will
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How to fill out spousal surcharge form
How to fill out spousal surcharge form
01
Obtain a copy of the spousal surcharge form.
02
Read the instructions and familiarize yourself with the requirements.
03
Fill in your personal details, such as your name, address, and contact information.
04
Provide information about your spouse, including their name, date of birth, and social security number.
05
Determine whether your spouse has access to employer-sponsored health insurance.
06
If your spouse has access to employer-sponsored health insurance, provide the relevant information, such as the name of the insurance provider and the coverage details.
07
If your spouse does not have access to employer-sponsored health insurance, indicate that on the form.
08
Sign and date the form, certifying the accuracy of the information provided.
09
Keep a copy of the completed form for your records.
10
Submit the form according to the instructions provided, either by mail or online.
Who needs spousal surcharge form?
01
The spousal surcharge form is typically required by individuals who have access to employer-sponsored health insurance and want to include their spouse in the coverage. However, the specific requirements may vary depending on the insurance provider and the employer's policies. It is recommended to consult with your employer or insurance provider to determine if the spousal surcharge form is necessary in your situation.
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