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UD Double State Share (DSS) Coverage Verification Form
UD Double State Share (DSS) Coverage Verification Form
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UD Double State Share (DSS) Coverage Verification Form
IMPORTANT: If you are enrolled or enrolling in one of the University’s DSS health plans, you must complete a DSS Verification Form each year after Open Enrollment to confirm eligibility for continued coverage. If you are enrolled in one of the DSS health plans, you will receive a notification to complete the form. Failure to complete the DSS Verification Form may result in loss of eligibility for enrollment in a DSS plan.
Employee | Pensioner Information
First Name
Last Name
Emplid
Email
Please ensure the email address is typed correctly as this is where email confirmation will be sent.
Phone
XXX-XXX-XXXX
Employee | Retiree Status
Active University of Delaware Employee
Retired University of Delaware Employee
University of Delaware Long Term Disability Beneficiary
Spouse Information
Spouse's First Name
Your spouse's name
Spouse's Last Name
Your spouse's surname or family name
Date Of Marriage
(mm/dd/yyyy)
Divorced
No
Yes
Date of Divorce
(mm/dd/yyyy)
Spouse Status
State of Delaware Employee
Delaware Transit Corporation Employee or Retiree
Delaware Solid Waste Authority Employee or Retiree
University of Delaware Employee or Retiree
Delaware State Housing Authority Employee or Retiree
State of Delaware Long Term Disability Beneficiary
State of Delaware Pensioner
Spouse deceased
Spouse State Hire Date
(mm/dd/yyyy)
Spouse employing agency/school district, or charter
Spouse Employee ID
Spouse Pension ID
Is the spouse receiving a pension check?
No
Yes
Are you receiving a survivor’s pension?
No
Yes
Certification
I affirm that the information I have provided on this form is accurate and complete.
Employee Signature
Other Fields
Your name
Your first name
Your last name
Your email address