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NECA/IBEW FAMILY MEDICAL CARE PLAN 5837 Highway 41 North Ringgold GA 30736 http //www. NIFMCP. com Phone 706 937-9600 Fax 706 937-9601 Toll Free 877 937-9602 SPOUSE EMPLOYMENT DATA FORM YOU AND YOUR SPOUSE MUST SIGN WHERE INDICATED BELOW. 1. EMPLOYEE INFORMATION* 1. Full name 2. SSN or Indiv* ID 3. Address 4. Marital status single married divorced other explain 2. SPOUSE INFORMATION* 1. Full name of spouse 2. Spouse s SSN 3. Spouse s employment status not employed employed full-time employed part-time self-employed retired 4. Name and address of spouse s employer 5. Contact person and telephone number at spouse s employer 6. Date of hire 7. Does spouse s employer offer a healthcare plan for its employees yes no 8. Is spouse eligible to enroll in employer s healthcare plan yes no 9. Is spouse enrolled yes no WORKING SPOUSE RULE* This Plan requires that your spouse enroll in his or her employer s health plan* If your spouse fails to enroll this Plan will reduce its benefits to 20 of covered charges. If your spouse s employer offers health coverage but your spouse is not eligible to participate you must submit a letter from the employer on company letterhead that explains the reason for his or her ineligibility. There is a hardship exemption to the working spouse rule for spouses earning a less than 20 000 per year or b between 20 000 and 30 000 per year if the coverage costs your spouse more than 150 per month. Answer No* 10a and 10b below ONLY if you want to claim the hardship exemption* In addition attach a letter attesting to wages and cost of coverage from the employer on company letterhead* 10a* Annual salary for current calendar year 10b. Amount employee pays per month If not enrolled when is spouse s next enrollment opportunity When would coverage begin Answer the following questions if spouse is enrolled in his or her employer s healthcare plan* 12. Give name and address of insurance company/plan or attach a photocopy of both sides of medical ID card 13. Plan information Group No* 3 all that apply 3. SIGNATURES* Indiv* ID No* major medical/PPO high deductible HRA HMO other explain single coverage family coverage other explain dental vision EMPLOYEE S SIGNATURE I affirm that the information given on this form is true and correct to the best of my ability. Employee s Signature Date SPOUSE S SIGNATURE AUTHORIZATION TO RELEASE INFORMATION I hereby authorize my employer to release information regarding my employer s health plan and my eligibility for coverage under that plan to the NECA/IBEW Family Medical Care Plan FMCP. This authorization shall remain in effect as long as I am eligible for benefits under the FMCP. I affirm that the information provided on this form is true and correct to the best of my ability. Spouse s Signature 4. SUBMIT TO FUND OFFICE* Mail completed form to the FMCP at 5837 Highway 41 North Ringgold GA 30736. EMPLOYEE INFORMATION* 1. Full name 2. SSN or Indiv* ID 3. Address 4. Marital status single married divorced other explain 2. SPOUSE INFORMATION* 1. Full name of spouse 2. Spouse s SSN 3. Spouse s employment status not employed employed full-time employed part-time self-employed retired 4.

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