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Revised Attestation Form Approved
Revised Attestation Form Approved
To be completed by ALL applicable employees who have a spouse enrolled in a Peak10 Benefit
Plan.
Instructions:
1.
2.
3.
4.
5.
Employee Name
1. ARE YOU LEGALLY MARRIED?
YES
(Continue to next step)
Location
NO (Sign and return to HR)
Spouses Name
2. IS YOUR SPOUSE EMPLOYED?
YES(Continue to question 3) NO (Sign and return to HR)
3. TO BE FILLED OUT BY SPOUSES EMPLOYER:
Spouses Employer Name
Spouses HR or Benefits Contact
Contact Phone Number
Is the above named employee eligible to
participate in their employers medical benefits
plan?
YES
NO