Office of Management and Budget : Benefits

SPOUSAL COORDINATION OF BENEFITS FORM

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If you cover your spouse in one of the State of Delaware's Group Health Insurance Plans; you MUST complete a new Spousal Coordination of Benefits form each year during Open Enrollment and anytime your spouse's employment or insurance status changes. If you do not complete a form, your spouse's coverage will be reduced to 20%.

Please read the acknowledgement sections at the end of this form carefully. You are responsible for understanding the requirements of the Spousal Coordination of Benefits Policy described here, for providing verification as noted, and for the accuracy of the information in this form.

Additional information not covered by the form should be entered into the "Comments" sections at the end of the form. If the first "Comments" section does not allow enough room, please continue in the next "Comments" section.

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Section Manager: Statewide Benefits Office

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Announcements / Notices | Benefits Documentation

Last Updated: Monday December 16 2013
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