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Download Shared Family Coverage - University of Northern Iowa
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Print Form Shared Family Coverage Faculty, P&S, Academic Administrators, Institutional Officials and Merit Supervisory & Confidential A. Coverage Plan: Select the health and dental insurance coverage from one of the following options: Option 1 Option 2 Option 3 Health UNI Health Health UNI Blue Advantage Health UNI PPO Dental UNI Dental Plan 1 Dental UNI Dental Plan 2 Dental UNI Dental Plan 2 B. Contract Holder Information Name: ___________________________ Last _____________________ First ______ MI University ID: ____________ ______ MI University ID: ____________ Department: ______________________________________________ C. Spouse’s Information Name: ___________________________ Last _____________________ First Department: ______________________________________________ The above named individuals, employees of the University of Northern Iowa, request a Shared Family Premium Arrangement. It is understood that the family contract will be in the Contract Holder’s name and Social Security number and that all claims must be filed in that person’s name. It is also understood that either spouse may be the contract holder. In the event that either employee terminates employment, becomes ineligible to participate in this program, or for some reason does not have any pay coming for any month in which a premium is due, the remaining employee, by his/her signature below, authorizes the appropriate deduction to be taken from his/her paycheck. If the Contract Holder terminates his/her employment with the University of Northern Iowa, the contract will be placed in the Spouse’s name and Social Security number and all claims must then be filed in that person’s name. Contract Holder’s Signature: _________________________________ Date: _______________________ Spouse’s Signature: ________________________________________ Date: _______________________ Revised 05/2016 BENEFITS 027 Gilchrist Cedar Falls, IA 50614-0034 Phone: 319-273-2422 Fax: 319-273-2927 http://www.uni.edu/hrs
