IMPORTANT INFORMATION About Your ELIGIBILITY For HEALTH ...

Putnam/Northern Westchester
BOARD OF COOPERATIVE EDUCATIONAL SERVICES
200 BOCES Drive, Yorktown Heights, NY 10598-4399
(914) 248-2455 FAX (914) 962-6819
March, 2006
IMPORTANT INFORMATION About
Your ELIGIBILITY For HEALTH INSURANCE
Annual Certification of Spousal and Dependent Eligibility
For July 2006– June 2007
In accordance with your district’s Working Spouse Rule, each employee/ retiree with
family coverage must complete the enclosed Certification of Spousal Earnings form
annually if your district is providing primary coverage (hospital, medical or
prescription drug benefits) for your spouse (and/or children depending upon the
birthday rule). This form does not need to be completed if your spouse (and children
when applicable) is covered by another insurance plan provided by his/her own
employer that is primary.
If your district is providing primary coverage for your spouse (and children when
applicable), then your contribution towards the premium will be increased by the
“buy-in” amount unless the conditions specified on the enclosed Summary
Explanation are met. If the conditions are met, then the “buy-in” will not be
assessed.
Certification of Spousal Earnings forms must be returned to the Office of Risk
Management at BOCES, 200 BOCES Drive, Yorktown Heights, NY 10598 NO
LATER THAN May 1, 2006. Failure to return the form or submission of an
incomplete form may result in assessment of the “buy-in”, or delayed or
suspended enrollment. Please remember that this form must be filled out every
year if your spouse receives primary coverage (hospital, medical or prescription
drug benefits) from your school district!
ALL members with family coverage should receive this mailing. IF YOU ARE A
SINGLE PARENT THIS FORM MUST BE COMPLETED. If you believe that it
is not applicable to you, please disregard.
Note:
The PNW BOCES administers the working spouse rule on behalf of
your school district or BOCES.
Enclosures:
Working Spouse Rule Summary Explanation (2 sided)
Working Spouse Rule Certification Form (2 sided)
Service and Innovation Through Partnership

Certification of Spousal and Dependent Eligibility: July 1, 2006– June 30, 2007
In accordance with the Working Spouse Rule, enrollment of a spouse (and other dependents when applicable) may
result in additional cost to the employee/ retiree. To certify that your spouse/ dependents are eligible for coverage
without the additional cost, you must complete and return this form by May 1, 2006. THIS FORM MUST BE
FILLED OUT EVERY YEAR! Failure to return the form or submission of an incomplete form may result in
additional cost to you.
A. Name of Employee/Retiree B. Spouse’s Name
Social Security # Social Security #
School District
Date of Marriage
Date of Birth
Date of Birth
Active □ Retired □ COBRA □
Employed □ Self-Employed □ Retired □
Unemployed □
Home Address
Name and address of present employer or business
(must be completed)
Home phone
Work phone
C. Is your spouse covered by another health plan other than yours? □No □Yes If yes, name
My spouse is covered by □Part A of Medicare and/or □Part B of Medicare
D. My spouse’s annual earnings in 2005 were:
1. _____More than $98,269 2. _____Less than $98,269 but more than $38,926 3. _____Less than $38,926
Earnings includes
• all wages, salaries, tips, etc. of the spouse; and
• any wages, salaries, tips etc. of the school district (or BOCES) employee/ retiree that are paid by any business or corporation in which
the spouse and/ or school district (or BOCES) employee/ retiree is a full or partial owner.
• If the spouse and/ or school district (or BOCES) employee/ retiree is a full or partial owner of any business or corporation, earnings
also includes a pro-rata share of the business’ and/ or corporations’ taxable income, ordinary income or net profit. For example, if the
spouse and school district employee each own 25% of a corporation’s stock, then 50% of the corporation’s taxable income would be
considered.
• Other income, excluding pension income.
E. SINGLE PARENTS □Widowed □Not married □Divorced
Are children covered under any other health plan? □No □Yes
If yes, name ___________________________
REVERSE SIDE OF FORM MUST BE COMPLETED
Form-WSRCERT2006front
Service and Innovation Through Partnership

BLOCK “F” MUST BE COMPLETED BY THE SPOUSE’S EMPLOYER.
(If self-employed, unemployed or retired, disregard block “F”.)
BLOCK “G” MUST BE SIGNED BY EMPLOYEE/RETIREE
F (1) The spouse named in block B is not covered by a health plan offered through his/ her own
employer that provides hospital, medical/ surgical and prescription drug benefits.
Please check the applicable box:
S/he selected alternative benefits or cash, such as through a cafeteria plan;
S/he failed to elect health benefits during an initial or open enrollment period;
Next open enrollment date is______________;
S/he is a new hire still in a waiting period. S/he will be eligible_________________.
Health benefits are not offered to any employee in his/her employment category;
Other; please explain.____________________________________________________
F (2) If s/he did elect benefits, would s/he be required to make a contribution toward the premium?
Yes No
If yes,
F (3) How much is the total premium? (total premium is employer share + employee contribution)
___________________
F (4) How much would the employee have to contribute for a single plan? ___________________
F (5) How much would the employee have to contribute for a family plan?___________________
___________________________________________
Print name of spouse’s employer’s representative
_________________________
Date
_____________________________________________________________________________
Signature of spouse’s employer’s representative
________________________________________
Title
__________________________
Phone number
Don’t Forget to
sign Block
“G”
G. Employee’s/ Retiree’s certification
I hereby certify that the information contained in blocks A-E on the reverse side is true
and complete. I understand that filing a statement to defraud is a criminal act. Block F
has been completed by my spouse’s employer, if applicable.
__________________________________________________________
Employee’s/ Retiree’s signature / ________________ Date
Return this form no later than
May 1, 2006 to:
Office of Risk Management,
Putnam/ North. West. BOCES
200 BOCES Drive, Yorktown Heights, NY 10598
Service and Innovation Through Partnership