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2016 Benefits Guide
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The Donald Danforth Plant Science Center
SPOUSE/DOMESTIC PARTNER PREMIUM SURCHARGE
___________________________________________________
____________________________________
Employee Name (please print)
Department
Effective January 1, 2016, the Danforth Center will add a
$50 monthly premium surcharge
to the Plan premiums for
employees who elect to cover a spouse or domestic partner employed full-time outside of the Danforth Center who is
eligible for health insurance through his or her own employer’s plan. The premium surcharge will be in addition to the
applicable Danforth Center health premium. Please complete the information on this affidavit relating to your spouse’s/
domestic partner’s employment outside of the Danforth Center.
Spouse/Domestic Partner Premium Surcharge
Yes
No
Is your Spouse or Domestic Partner employed outside of the Danforth Center on a full-time basis?
If yes, does your Spouse or Domestic Partner have health insurance available through his
or her own employer?
Do you want to cover your Spouse or Domestic Partner under the Center’s health plan?
I certify and warrant to the Danforth Center that all information on this spousal/domestic partner verification
affidavit is true, correct and current as of the date signed. I agree to provide supporting documentation upon the
request of the Danforth Center. I understand if I knowingly submit false information, my coverage may be
terminated and I may be subject to disciplinary action up to and including termination of employment.
If indicated above, please remove my spouse/domestic partner from any health plan I am enrolled in for
2016.
________________________________________
________________________________
Employee Signature
Date
Submit completed form by December 11, 2015 to:
Vicky Wertich, Human Resources
975 N. Warson Road
St. Louis, MO 63132