If you have listed a common law spouse as a dependent on your Health & Welfare
Plan Enrolment Card. You must 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.