Complete this form if you have a spouse/partner enrolled ...

Complete this form if you have a spouse/partner enrolled in a Caterpillar healthcare plan

Caterpillar Affidavit of Spousal Surcharge Compliance

We__________________________________, and__________________________________________

Employee

Eligible Spouse/Partner

Certify that the following are true. Please place an "X" next to the one that applies to you:

1. ______ Named spouse is not employed and does not have access to an employer-sponsored health plan. (Spousal surcharge does not apply.)

2. ______Named spouse has access to an employer-sponsored health plan, has declined his or her employer's healthcare coverage and has enrolled in a Caterpillar healthcare plan for primary coverage. (Spousal surcharge applies.)

3. ______Named spouse has other healthcare coverage through his or her employer or a Medicare/Medicaid option as primary coverage and is enrolled in a Caterpillar healthcare plan for secondary coverage. (Spousal surcharge does not apply.)

4. ______Named Spouse is employed but is not eligible for an employer-sponsored health plan and is enrolled in a Caterpillar healthcare plan. (Spousal surcharge does not apply). Please provide your spouse's employer information below:

Employer Name: ________________________________________

Employer Address: ________________________________________

________________________________________

Employer Phone #: ________________________________________

Employer Signature: ________________________________________

(Employer's: Human Resources, benefits representative, etc.)

We acknowledge that the above statement is true and correct. We understand that a false statement on this affidavit may result in application of the spousal surcharge.

____________________________ ______________________________ _____________________ _____

Employee Name (Printed)

Employee Signature

Date

____________________________ ______________________________ __________________________

Spouse Name (Printed)

Spouse Signature

Date

Return Options Fax: 847-554-1473 Upload: Mail: Caterpillar Benefits Center DEPT 02358 P.O. Box 1590 Lincolnshire, IL 60069-1590

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