Employer’s Healthcare Insurance Cost Verification For P&G ...

1 Employer's Healthcare Insurance cost Verification For P&G. Spouses/Dependents/Household Dependents/Domestic Partners Human Resources/Benefits Department: My _____ is eligible to enroll me in the health care plan being offered by his/her employer. He/She may or may not be required to pay an additional fee for my coverage. The decision depends on whether coverage is available to me by my employer and if so, what the coverage will cost me. In order to determine if coverage is available to me through you, my employer, and what the cost to me would be for coverage, documentation must be provided. Please complete the appropriate item below and return it to me: Employee's employment status _____ Full-Time _____Part Time Is single person health care Insurance offered to full-time employees? _____. Is single person health care Insurance coverage offered to part-time employees? _____.

2 Employer's monthly contribution rate (COBRA rate) for single coverage in lowest cost plan? _____. Employee's monthly premium for single coverage in lowest cost plan $_____. Next date that enrollment may be completed by this employee _____. _____. (Name of Company Representative providing Verification ). _____. (Signature of Company Representative providing Verification ). _____ _____. (Date) (Phone number). _____. This section should be completed by the P&G employee. Name of P&G Employee_____. Name of Spouse/Dependent/Household Dependent/Domestic Partner_____. Date Submitted By P&G Employee_____. NOTE: A SPOUSE/DEPENDENT/HOUSEHOLD DEPENDENT/DOMESTIC PARTNER WHO IS SELF- EMPLOYED MUST COMPLETE THIS FORM AS THE EMPLOYER. PHOTOCOPIES OF THIS FORM WILL NOT BE ACCEPTED.