Declaration of Domestic Partnership Same and Opposite Sex Couples

Group health coverage, including medical, dental and voluntary AD&D insurance, is available for domestic partners of eligible employees.

We, _______________________________________ (Employee – Print Name) and ________________________________ (Domestic Partner – Print Name) certify and declare that we are domestic partners in accordance with the following criteria and are eligible for Medical, Dental, and voluntary AD&D insurance benefits under Medica Health Plans benefits program.

1. 
   The partners have had a single, committed relationship of mutual caring for at least twelve (12) months and intend to remain in the relationship indefinitely;
   

2. 
   The partners share the same permanent residence and have done so for at least twelve (12) months;
   

3. 
   The partners are not related by blood or a degree of closeness which would prohibit marriage under the law of the state in which they reside;
   

4. 
   Neither partner is married as defined by federal or common law to another person, and neither is a member of another domestic partnership;
   

5. 
   Each partner is mentally competent to consent or contract;
   

6. 
   Both partners are at least 18 years of age; and
   

7. 
   The partners are financially interdependent, jointly responsible for each other’s basic living expenses and if asked, be able to provide documents proving at least three of the following situations to demonstrate such financial interdependence:
   
   1. 
      Joint ownership of real property or a common leasehold interest in real property;
      
   2. 
      Common ownership of an automobile;
      
   3. 
      Joint bank or credit accounts;
      
   4. 
      A will which designates the other as primary beneficiary;
      
   5. 
      A beneficiary designation form for a retirement plan or life insurance policy signed and completed to the effect that one partner is a beneficiary of the other; or
      
   6. 
      Designation of one partner as holding power of attorney for healthcare decisions for the other.
      

Please consult a tax advisor before you certify that your domestic partner seeking coverage is a dependent as defined by the Internal Revenue Code. If your answer is YES, you are not taxed on the employer contribution for the dependent coverage premiums paid by Medica Health Plans, and you are able to make contributions for the domestic partner’s coverage on a pre-tax basis.

Please check one:

�� Yes, my domestic partner qualifies as my dependent for Federal income tax purposes.

I understand that on the basis of the above statements, Medica Health Plans will consider the above person my dependent for all federal income and employment tax purposes.
I agree to reimburse Medica Health Plans for any and all liability including, without limitation, taxes, penalties or losses (including reasonable attorneys’ fees) that Medica Health Plans may incur arising out of its reliance on this affidavit if it is untrue in any respect or if I fail to provide the notice required by paragraph IV.
�� No, my domestic partner does not qualify as my dependent for Federal income tax purposes. I understand that I will be charged imputed income as applicable to my enrollment from the charts that follow.
IV. CHANGE IN DOMESTIC PARTNERSHIP

1. We agree to notify Medica Health Plans as required by this Section IV if there is any change in our status as domestic partners as attested in this Declaration which would make the domestic partner and/or any of his/her dependent children ineligible for Medica Health Plans benefits program (for example, due to the death of a partner, a change in joint –residence, termination of the relationship, etc.)

1. We understand that any person/employer/insurer/claims administrator who suffers any loss due to any false statement contained in this Declaration may bring civil action against either or both of us to recover their losses, including reasonable attorney’s fees.

We declare, under penalty of perjury, under the laws of the state of Minnesota that the assertions in this Declaration are true to the best of our knowledge. We understand that this form is not an application for insurance overage and that the purpose for this form is to establish eligibility of person named herein for the coverage provided under Medica Health Plans benefits program.