See the D.A. Townley COVID-19 Update

Health Benefits —

Spousal Declaration

Common Law Spouse Declaration

If you have listed a common law spouse as a dependent on your Health Benefit Plan Enrolment Card, you may be required to complete the Common Law Spouse Declaration form and submit with your enrolment card for your common law spouse to be eligible for Extended Health and Dental coverage.

Information Needed to Complete the Form
To complete the form, the following information is needed:

  • Member’s name and address,
  • Common law spouse’s name,
  • Address at which you are currently residing, and
  • Signature of a Notary Public or Commissioner for taking Affidavits.

A licensed Notary Public or Commissioner must sign the form before you send it to the Plan Administrator.

Completed forms should be forwarded to the Plan Administrator.

More Information
Questions on completing the form should be directed to the Plan Administrator.

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