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XYZ Company

DOMESTIC PARTNER BENEFITS

INTRODUCTION

The XYZ Company continues its practice of providing diverse benefit policies by offering its employees the opportunity to include a domestic partner in eligible benefits.

ELIGIBILITY

All regular, full-time and part-time employees (both exempt and non-exempt) who have successfully completed the probationary period and have demonstrated to the United Way’s satisfaction that they have a domestic partner, are eligible for Domestic Partner Benefits. Current employees may enroll for Domestic Partner Benefits as of 04/01/01, or during open enrollment, or within 30 days after meeting the eligibility requirements.

DOMESTIC PARTNER DEFINITION

XYZ Company defines partners as two people who are either of the same or opposite sex in a spouse-like relationship who have met all of the following requirements for at least the last 12months:

  • Are both at least 18 years of age (upon electing to participate in this policy) and mentally competent to enter into a legal contract;
  • Share an emotionally committed relationship and intend to remain each other’s domestic partner indefinitely;
  • Reside together in the same permanent residence currently and for the last 12months;
  • Are jointly responsible for the common welfare and financial obligations of the household, or the domestic partner is chiefly dependent upon the employee for care and financial assistance for at least the last 12months;
  • Are not legally married to anyone else and are not the domestic partner of anyone else for at least the last 12months;
  • Are not related by blood closer than would bar marriage under New YorkState law.

COST TO THE EMPLOYEE

Domestic partner coverage will cost the same as “Family” medical and dental coverage. Part-time employees who elect to participate in this plan will be charged according to a pro-rated rate. Please refer to the “benefits at a glance” for a detailed outline of these expenses.

DOCUMENTATION REQUIRED FOR DOMESTIC PARTNERS

At least three of the following sources of documentation must be submitted as proof of domestic partnership and financial interdependence, and at least two of the three items must be from ListA:

LIST A / LIST B
  • Joint obligation on a loan (including an affidavit by a creditor for a personal loan)
  • Joint ownership of residence
  • Joint renters’ or home owners’ insurance policy
  • Joint responsibility for child care (i.e., school
documents, guardianship)
  • Designated as beneficiary under the other’s life insurance policy, retirement benefits account or will or executor of each other’s will
  • An affidavit by a creditor able to testify to
partner’s financial interdependence
  • Designation of one partner as the representative payee for the other’s government benefits
  • Joint ownership or holding of investments
  • Joint ownership or lease of a motor vehicle
  • Both listed as tenants on the lease of shared
Residence
  • Mutually granted authority to make health care
decisions (i.e., health care power of attorney)
  • Mutually granted durable power of attorney
/
  • Joint bank account
  • Joint credit or charge card(s)
  • Status as authorized signatory on the partner’s bank account, credit card or charge card
  • Other proof establishing economic
Interdependence

Note: The items submitted for proof of domestic partnership pertaining to joint ownership or responsibility need not be shared equally (i.e., mortgage payments need not be split 50/50).

VERIFICATION

In addition to the above, you and your domestic partner must each complete and sign an “Affidavit of Domestic Partnership” to confirm that the above conditions have been met.

DOMESTIC PARTNER BENEFITS

Domestic partners of employees who qualify for domestic partner benefits are eligible for the majority of benefits XYZ Company offers. However, integrating domestic partners into our existing benefit plans requires some distinctions. The chart below indicates what is generally available to domestic partners. XYZ Company reserves the right to amend or revise these policies without notice, and these policies are subject to change without notice.

HEALTH CARE / All health care plans offered by United Way will enroll domestic partners.
DENTAL / Dental enrollment is offered to domestic partners through Guardian Insurance.
LIFE INSURANCE / Your domestic partner or any other person may be elected as your life insurance beneficiary at any time during your employment.
ADDITIONAL LIFE INSURANCE / You can insure the life of your domestic partner and his or her children using the spouse and child options available to all employees.
BEREAVEMENT LEAVE / A domestic partner and his or her children are defined by XYZ Company as “immediate family.”
FAMILY & MEDICAL LEAVE ACT
*Note: the Federal Government applies FMLA to spouses only. UW is including domestic partners. / This unpaid leave of absence will extend to an employee’s domestic partner’s serious health condition.
PENSION / In accordance with the plan, your domestic partner or any other person may be elected as your pension policy beneficiary at or near your retirement. However, only spouses are considered under pre-retirement survivorship benefits.
EMPLOYEE ASSISTANCE PROGRAM / This program includes confidential assessment, consultation, referral and follow-up to help you and any member of your household (including domestic partners and dependents) to resolve serious personal problems.
PREMIUM ONLY PLAN
*Note: the Federal Government does not recognize domestic partners. / The premium only pre-tax benefit may not be used for domestic partners unless they are a dependent under IRS Section 152, as these benefits are taxable.
COBRA / Your domestic partner or his or her dependents are not eligible for Cobra under Federal Law.
FLEXIBLE SPENDING ACCOUNTS / Domestic partners are not eligible to participate in FSA’s unless they are a dependent under IRS Section 152.

DEPENDENT COVERAGE

Dependent coverage will continue up to and including the last day of the calendar year that the child attains the age of 19, or the age of 23 if the dependent is a full-time student (whichever comes last). The coverage will continue based on your medical insurance through United Way.

CONTINUING DOMESTIC PARTNER COVERAGE

After enrolling in domestic partner benefits, you may not change your benefit plan until the next open enrollment period unless you have a change in family status or your employment status changes.

TERMINATION OF COVERAGE OF DOMESTIC PARTNER

The coverage of a domestic partner shall terminate when such individual is no longer within the definition of domestic partner. The employee shall immediately inform United Way of any change to the domestic partner relationship and thus domestic partner benefits will no longer apply. Such changes include, but are not limited to: marriage, death, student status, age or legal status of children, domestic partner no longer meeting the definition contained in this policy, and change of address. Your domestic partner’s coverage will continue until the last day of the month in which the coverage is terminated.

AFFIDAVIT OF DOMESTIC PARTNERSHIP - EMPLOYEE

STATE OF NEW YORK

COUNTY OF ERIE

______, being duly sworn, deposes and says:

(Name of employee)

  1. I am an employee of the United Way of Buffalo & Erie County (“United Way”) and have successfully completed my probationary period. I am submitting this affidavit in order to obtain Domestic Partner Benefits for my domestic partner, ______,

(Name of domestic partner)

pursuant to the United Way’s policy.

  1. I am _____ years of age and I live at ______

______.

(Full address)

  1. ______has been living with me since ______

(Name of domestic partner)(Relevant date)

(Must be at least 12months).

  1. ______and I are jointly responsible for the common

(Name of domestic partner)

welfare and financial obligation of the household [or the domestic partner is chiefly dependent upon me for care and financial assistance].

  1. I am not legally married to anyone else, nor am I the domestic partner of anyone else. ______and I are not related by blood closer than

(Name of domestic partner)

would bar marriage under New YorkState law.

  1. The relationship I share with ______ is a committed

(Name of domestic partner)

relationship, which we intend to be permanent.

  1. ______

[Any additional information to support domestic partner status. THIS IS OPTIONAL.]

  1. I have reviewed and understand the United Way’s policy on Domestic Partner Benefits and I have assisted in submitting the required documentation.
  1. I understand that I would be well advised to consult an attorney regarding any possibility that the filing of this affidavit may have certain legal consequences, including the fact that it may, in the event of termination of a domestic partner relationship, be regarded as a factor leading a court to treat the relationship as the equivalent of marriage for the purpose of establishing and dividing community property, or for ordering payment of support.
  1. I understand that I have an obligation to file a Benefit Enrollment Change Form with the United Way’s Human Resources Department within 30 days of the date on which any criteria of the Domestic Partner Benefit Policy is no longer being met.
  1. I understand that I am responsible for reimbursement of any expenses incurred as a result of any false or misleading statement contained in this affidavit concerning my domestic partner relationship.
  1. I affirm, under penalty of perjury, that statements in this affidavit are true to the best of my knowledge. I understand that if any information is not true and correct, the United Way reserves the right to take disciplinary action, up to and including termination of employment.

______

[Signature of employee]

Sworn to before me this

____ day of ______, 20__.

______

Notary Public

AFFIDAVIT OF DOMESTIC PARTNERSHIP - PARTNER

STATE OF NEW YORK

COUNTY OF ERIE

______, being duly sworn, deposes and says:

(Name of domestic partner)

  1. I am the domestic partner of ______, an employee of the

(Name of employee)

United Way of Buffalo and ErieCounty (“United Way”). I am submitting this affidavit in order to obtain Domestic Partner Benefitspursuant to the United Way’s policy.

  1. I am _____ years of age and I live at ______

______.

(Full address)

  1. ______has been living with me since ______

(Name of employee)(Relevant date)

(Must be at least 12months).

  1. ______and I are jointly responsible for the common

(Name of employee)

welfare and financial obligation of the household [or the employee is chiefly dependent upon me for care and financial assistance].

  1. I am not legally married to anyone else, nor am I the domestic partner of anyone else. ______and I are not related by blood closer than

(Name of employee)

would bar marriage under New YorkState law.

  1. The relationship I share with ______ is a committed

(Name of employee)

relationship, which we intend to be permanent.

  1. ______

[Any additional information to support domestic partner status. THIS IS OPTIONAL.]

  1. I have reviewed and understand the United Way’s policy on Domestic Partner Benefits and I have assisted in submitting the required documentation.
  1. I understand that I would be well advised to consult an attorney regarding any possibility that the filing of this affidavit may have certain legal consequences, including the fact that it may, in the event of termination of a domestic partner relationship, be regarded as a factor leading a court to treat the relationship as the equivalent of marriage for the purpose of establishing and dividing community property, or for ordering payment of support.
  1. I understand that I am responsible for reimbursement of any expenses incurred as a result of any false or misleading statement contained in this affidavit concerning my domestic partner relationship.
  1. I affirm, under penalty of perjury, that statements in this affidavit are true to the best of my knowledge.

______

[Signature of domestic partner]

Sworn to before me this

____ day of ______, 20__.

______

Notary Public