Spouse Eligibility Requirements Form

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Spouses who have access to Medical/Rx Insurance coverage through their own employment may be charged an additional surcharge for their coverage through Hope College. To determine if the surcharge is applicable, the information below MUST be reported each year during open enrollment AND anytime throughout the year if spouses’ coverage situation changes (within 30 days of event) .

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My spouse is not employed. (Surcharge will not apply.)

My spouse's primary employment is at Hope College (part-time or full-time). (Surcharge will not apply.)

My spouse is self-employed and does not have access through his/her company. (Surcharge will not apply.)

My spouse is employed but does not have access through his/her employment. (Surcharge will not apply.)

My spouse is employed and has elected primary coverage through his/her employer but we desire secondary coverage through the Hope College health plan. (Surcharge will not apply.)

My spouse is employed and has access through his/her employment which we have declined and chose to continue my spouse’s coverage through the Hope College health plan. (Surcharge will apply.)

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