Domestic Partner Affidavit - Group Health Plan Dependent Enrollment

Sep 16, 2026

Uploaded by Mack Lee

Domestic Partner Affidavit form for certifying that a domestic partner meets eligibility requirements for enrolling the partner as a dependent under an employee’s group health plan. Collects employee and group identifiers, registration status within the prior six months, and definitions of qualifying domestic partners. Requires proof of cohabitation and financial interdependence through specified supporting documents, and includes controlling policy language plus an employee and domestic partner attestation with notarization.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Domestic Partner Affidavit

Purpose and Certification

Registration Requirement

Domestic Partner Eligibility Requirements

Evidence of Cohabitation

Evidence of Financial Interdependence

Controlling Policy

Attestation and Signatures

Notary Public Section

Submission Instructions

DOMESTIC PARTNER AFFIDAVIT The purpose of this Affidavit is to certify that your partner meets the following Domestic Partnership requirements for the purposes of enrolling your partner as a dependent under your group health plan. Employee Name Identification Number Group Name Group Number 1. Registration as a domestic partnership indicating that neither individual has been registered as a member of another domestic partnership within the last [six (6)] months, where such registry exists ☐ Yes – Please list what state you and your Domestic Partner are registered in: (Provide a copy of the Domestic Partner Registry that is filed in the county clerk’s office) * ☐ No – Move to the next section. * IF YOU PROVIDE A REGISTRATION OF DOMESTIC PARTNERSHIP, INDICATING THAT NEITHER INDIVIDUAL HAS BEEN REGISTERED AS A MEMBER OF ANOTHER DOMESTIC PARTNERSHIP WITHIN THE LAST SIX (6) MONTHS (WHERE SUCH REGISTRY EXISTS), NO FURTHER INFORMATION IS REQUIRED. A Domestic Partner is defined as a member of a Domestic Partnership consisting of two partners (of the same or opposite sex) . In order to qualify for group health coverage, you must meet all of the following requirements: A. B. C. D. ☐ Yes ☐ Yes ☐ Yes ☐ Yes ☐ No ☐ No ☐ No ☐ No The partners are both 18 years of age or older and are mentally competent to consent to contract; The partners are not related by blood in a manner that would bar marriage under laws of the State of New York; The partners have been living together on a continuous basis prior to the date of the application; Neither individual has been registered as a member of another domestic partnership within the last six (6) months In addition to the above requirements, evidence of a Domestic Partnership must exist. Proof of Cohabitation and Financial interdependence must be submitted (Proofs should be clearly unaltered copies of original documents) . 1. As evidence of Cohabitation, please attach one of the following documents to this Affidavit: ☐ Driver’s License; ☐ Tax Return; ☐ Bank Statement; ☐ Joint mortgage or lease on the primary residence listing both parties; ☐ Paycheck stub; ☐ Utility bill; or ☐ Auto registration Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield isan independent licensee of the Blue Cross Blue Shield Association 2. As evidence of Financial Interdependence, provide two of the following documents with this Affidavit: ☐ A joint bank account; ☐ A joint credit card or charge card; ☐ Joint obligation on a loan; ☐ Status as an authorized signatory on the partner’s bank account, credit card or charge card; ☐ Joint ownership of holdings or investments; ☐ Joint ownership of residence; ☐ Joint ownership of real estate other than residence; ☐ Listing of both partners as tenants on the lease of the shared residence; ☐ Shared rental payments of residence (need not be shared 50/50); ☐ Listing of both partners as tenants on a lease, or shared rental payments, for property other than residence; ☐ A common household and shared household expenses, e.g., grocery bills, utility bills, telephone bills, etc. (need not be shared 50/50); ☐ Shared household budget for purposes of receiving government benefits; ☐ Status of one as representative payee for the other’s government benefits; ☐ Joint ownership of major items of personal property (e.g., appliances, furniture); ☐ Joint ownership of a motor vehicle; ☐ Joint responsibility for childcare (e.g., school documents, guardianship); ☐ Shared child-care expenses, e.g., babysitting, day care, school bills (need not be shared 50/50); ☐ Execution of wills naming each other as executor and/or beneficiary; ☐ Designation as beneficiary under the other’s life insurance policy; ☐ Designation as beneficiary under the other’s retirement benefits account; ☐ Mutual grant of durable power of attorney; ☐ Mutual grant of authority to make h

FAQs

What is the purpose of this Domestic Partner Affidavit?

It certifies that the employee’s domestic partner meets required domestic partnership criteria to be enrolled as a dependent under the employee’s group health plan.

What registration condition must be met regarding other domestic partnerships?

The affidavit requires that neither individual has been registered as a member of another domestic partnership within the last six (6) months, where such registry exists.

What documents are needed as evidence of a domestic partnership?

Proof of cohabitation and proof of financial interdependence must be provided using the listed document options, including clearly unaltered copies of originals.

Sep 16, 2026

Uploaded by Mack Lee