HUMAN RESOURCES
emich.edu
Return to: Eastern Michigan University Benefits Office
140 McKenny Hall, Ypsilanti, MI 48197 | 734.487.3195 | Fax: 734.487.4389
Revised: 8/29/2016
Health Plan Affidavit for Spouses
Employee Name: _____________________________________________
Social Security Number: _____________________ Employee ID: E_________________________
If you are an Eastern Michigan University (EMU) employee who has selected medical/dental coverage for your spouse, you
must complete this form. Failure to complete and return this affidavit will result in removal of your spouse from your
medical and/or dental plan, effective January 1, 2017.
Is your spouse currently employed? Yes, at an employer other than Eastern Michigan University (continue to Section II)
Yes, at Eastern Michigan University (continue to Section III)
Self-employed (continue to Section III)
Not employed / Retired (continue to Section III)
Please note that if your spouse’s employer provides subsidized group medical/dental* coverage, your spouse must enroll in
the spouse’s employer’s plan. Your spouse will no longer be eligible for coverage under Eastern Michigan University’s
medical/dental plan, effective January 1, 2017. This loss of eligibility would be considered a “qualifying event” allowing your
spouse to enroll in coverage with their employer. Your spouse may remain on EMU’s medical/dental plan as secondary
coverage only. *If you are an AP/AH/CA/AC employee, your spouse may enroll in primary dental coverage with EMU at the full
single rate, even if they have access to dental coverage through their employer.
Please note if both you and your spouse are employees of Eastern Michigan University, only one may elect primary coverage
through the university. The other spouse must be added as a dependent on his/her plan.
Please note Eastern Michigan University reserves the right to request information to verify the stated criteria are met. In the
event the supporting documents do not meet the University’s stated criteria, the University has the ability to deny coverage
under Eastern Michigan University’s medical plan.
Name of spouse: ________________________________________________________________________________________
Name of employer: ___________________________________________ Phone number of employer: __________________
Is your spouse eligible for subsidized medical/dental coverage through their employer?
Yes No Medical Only Dental Only
I understand that providing false information could result in disciplinary action up to and including termination of
employment. I also understand that I am responsible for the cost of any benefits paid on behalf of my spouse that were not
eligible for coverage through an EMU plan. I understand that by signing this document, I am certifying that my spouse is either
an employee of Eastern Michigan University, or ineligible for an employer subsidized medical/dental plan. I understand if my
spouse subsequently becomes eligible for “employee only” health plan coverage through his/her employer, he/she must
enroll in the other employer’s health plan coverage in order to maintain secondary coverage through EMU.
____________________________________ _________________
Employee Signature Date
SECTION II: Spouse Employment Information
SECTION III: Acknowledgment – must be signed by above-named Eastern Michigan University Employee
