Request for Waiver of Spouse/Partner Surcharge
You have elected to cover your spouse/partner under a University medical plan. As a result, a $100 monthly spouse/partner surcharge will be added to your medical insurance premium each month. Your waiver to be excluded from this surcharge is not automatic — you must request it each year. A waiver is available only if one of the following is true: Your spouse/partner is not employed. Your spouse/partner does not have access to employer-sponsored medical coverage with his/her employer where the employer pays at least 50% of the premium cost. Your spouse/partner is enrolled in medical coverage at his/her current or former employer. Lehigh's insurance will be secondary for him/her. Details about the spouse/partner surcharge can be found in the Flexible Benefits Enrollment and Reference Guide, under Benefits on the Human Resources home page. Whether you have elected medical coverage for your spouse/partner during the Open Enrollment period or as the result of a Qualifying Life Event (QLE), you will automatically be assessed the Spouse/Partner Surcharge of $100/month. To determine if you qualify to have this charge waived, you must complete this request. Spouse/partner surcharge amounts you pay before successfully completing the request cannot be refunded to you, even if the completed result confirms that you should not pay the surcharge going forward. To qualify for a waiver of the spouse/partner surcharge as a result of a Qualifying Life Event, your responses to this request MUST be received in Human Resources by either the 5th or the 20th of the month to avoid the waiver being applied to the next pay following the coverage change date.
Section I: Lehigh Employee Info
Employee Name:
Lehigh Email:	@lehigh.edu
Spouse/Partner's Full Name:
Select one of the choices below:
My spouse/partner is employed and
does not have access to employer-sponsored medical coverage for which the employer pays at least 50% of the cost.
has access to employer-sponsored medical coverage for which the employer pays at least 50% of the cost, but chooses not to participate in the medical coverage offered.
is enrolled in medical coverage through his/her employer.
My spouse/partner is not employed and
does not have access to medical coverage through a former employer.
has access to medical coverage for which a former employer does not pay at least 50% of the cost.
has access to medical coverage for which a former employer pays at least 50% of the cost, but chooses not to participate in the medical coverage offered.
is enrolled in medical coverage through a former employer.
My spouse/partner is self-employed (or an independent contractor) and
does not provide medical coverage to his or her employees
provides employer-sponsored medical coverage to his or her employees
Section II: Spouse/Partner Employer Info
I authorize Lehigh University to contact my spouse/partner’s employer for verification.
Employer Name:
Employer Telephone Number:
Section III: acknowledgment
I acknowledge that the information provided is true and complete to the best of my knowledge. Should I experience a Qualifying Life Event and want to make a change to my benefit elections, I understand that I am responsible for notifying Human Resources within 30 days of the event's occurrence. If I do not notify Human Resources within 30 days of the qualifying event, I must wait for the next Open Enrollment period (or another qualifying life event) to make a change to my benefits. I further understand that falsifying information regarding my spouse/partner’s medical coverage will result in, at a minimum, the request for waiver of the spouse/partner surcharge being denied.
Employee Signature:	Date: