Pipe Fitters Local No. 533 Health and Welfare Plan
8600 Hillcrest Road, Suite A  | Kansas City, Missouri 64138 | (p) 816.361.0206 |  (f)  816.444.4275

Employed Spouse Coverage Affidavit
Important: please ensure this form is fully completed.
Your response, or lack of response, will impact your spouse’s health care coverage.

SECTION I: Pipefitter and Spouse Information

Pipe Fitter Name:	Full Name of Spouse:	
Pipe Fitter Date of Birth:	Phone Number:	
Address:	

SECTION II: Employer Certification of Spouse’s Health Insurance Coverage

NOTE: this section must be completed in full by your Spouse’s employer

1.	Does your company/organization offer health insurance to your employees that is designed to satisfy minimum essential health coverage requirements under the Affordable Care Act?
□	Yes   □ No  If the answer to #1 is yes, please proceed to #2.  If no, please go to #5.
2.	As of March 31, 2018, is the Spouse named above eligible for your company/organization's health insurance coverage?
□	Yes   □ No  If the answer to #2 is yes, please proceed to #4.  If no, please go to #3.
3.	Why is the Spouse named above not eligible for your company/organization's health insurance coverage as of March 31, 2018?
□	The Spouse is not a full time employee	□ The Spouse is in a waiting period. and company health insurance coverage	(if checked, proceed to #5)
is not offered to part-time employees.
(if checked, proceed to #5)
□	The Spouse did not enroll during the	□ Other: 	                                                                Open Enrollment Period.	(if checked, proceed to #4)
(if checked, proceed to #4)

4.	What is the employee’s cost for the least expensive employee-only coverage option available (excluding any voluntary coverage buy ups, e.g. vision, dental, etc.)?  $ 	per 	.  Please complete #5.
5.	Employer Information:
Name of employer:	 	Phone:	 Address of employer:  		

Name of Representative (printed) 	Title: 	

Signature of Representative: 	Date: