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INSTRUCTIONS:Complete this Affidavit to confirm domestic partner eligibility. Please complete allapplicable sections, sign, and return the form to the Dependent Verification Center at: Dependent Verification Center, P.O. Box 1403, Lincolnshire, IL 60069-1403. You may also fax this to 1-866-961-6881.
If you would like to receive paperless notices in the future, please visit the Dependent Verification Portal site and enroll in paperless. You’ll have convenient and secure access to all notices and will get more timely notifications. You will receive email notification when a new notice is ready to review.
AFFIDAVIT OF COMMON LAW SPOUSE. We, the undersigned, being of lawful age, attest to the following facts: 1. We have lived together continuously as husband and wife from _______________ tothe present. During this period we have professed to be husband and wife and we have presented ourselves to the community as being married. 2.
Spouse/Domestic Partner Surcharge Affidavit. Please complete the following questions if you are covering your spouse/domestic partner on Anthem’s medical insurance:
We each certify and declare under oath that we are domestic partners in accordance with each of the following criteria: My partner is age 18 or older; My partner has lived with me for at least 12 months and we have a serious, committed relationship; My partner is financially interdependent with me; My partner is not related to me in a way that ...
Title: frm_rpt_pdf.aspx Author: AH0124901 Created Date: 3/14/2017 2:57:51 PM
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