Get Spousal Exclusion Request Form - Employees Benefits Department - Ebc State Ok

The Spousal Exclusion Request Form allows employees to elect to cover eligible dependent children while excluding their partner from health, dental, and vision coverage. This guide provides a step-by-step approach to filling out this form online, ensuring a clear and straightforward process.

Follow the steps to complete and submit your request online.

1. Click 'Get Form' button to obtain the form and open it in the online editor.
2. Begin by entering your agency name in the designated field at the top of the form.
3. Print your full name in the 'Employee’s Name' section, ensuring it is legible.
4. Fill in your agency number or location in the 'AGCY #/LOC' field.
5. Sign and date the form in the 'Employee’s Signature' section to confirm your election.
6. Proceed to enter your partner's full name in the 'Spouse’s Name' area, also ensuring clarity.
7. Provide your partner's Social Security Number in the corresponding field.
8. Enter your partner's date of birth accurately in the 'Spouse’s Date of Birth' section.
9. Have your partner sign and date the form in the 'Spouse’s Signature' area.
10. Select the options you wish to exclude by checking the appropriate boxes for Health, Dental, and Vision.
11. Once all fields are completed, review the information for accuracy before saving the form.
12. After confirming the details, save your changes, and proceed to download or print the completed form as needed.
13. Attach the original completed form to the appropriate enrollment or change form for submission.

Complete your Spousal Exclusion Request Form online today for efficient processing.