From: "Steven Greene" OVERVIEW OF PROPOSED PITZER COLLEGE 2 REIMBURSEMENT PLAN FOR DOMESTIC PARTNER HEALTH COVERAGE OBJECTIVE 4 The overall objective of the plan is to assist in providing, to the extent permitted by law, a measure of health expense 6 protection to employees in domestic partner arrangements that is comparable to that provided to employees in statutorily 8 recognized family/dependent arrangements. QUALIFICATIONS 10 In administering this plan the College will recognize for spousal equivalency status an unmarried, unrelated partner of any gender 12 whose emotional and financial relationship to an employee qualified them to be considered domestic partners. In addition, 14 the College will recognize for dependent equivalency status an unmarried dependent child, under age 19, of a qualifying domestic 16 partner. An employee wishing to participate in this plan will be required 18 to complete an application. The application will require the employee to certify that a committed relationship of shared 20 emotional and financial responsibility currently exists. Upon acceptance of the application by a designated representative of 22 the College, the domestic partner will be granted spousal equivalency status and the employee will be eligible for the 24 benefits described below. The employee has the right to withdraw application for spousal or 26 dependent equivalency status prospectively at any time. Unless application is withdrawn by the employee, spousal equivalency 28 status will be valid for as long as statutorily recognized family arrangements normally are. 30 The employee has the right to change the individual designated as a domestic partner. However, spousal equivalency status will be 32 granted to no more than one individual at any time. The College will make available general information and examples 34 of health plans obtainable in the open market that are accessible on an individual-purchase basis.[1] It is the responsibility of 36 the employee, or the partner, to select a plan, make application for, and to satisfy any eligibility or underwriting requirements 38 for coverage by the selected company.[2] BENEFIT 40 Contingent upon the domestic partner being granted spousal equivalency status, and upon presentation of proof of having 42 obtained individually issued health plan coverage for the domestic partner, the College will reimburse the employee for the --------------- 44 [1] The College will make every reasonable effort to identify health plans backed by companies with a record of good service 46 and financial stability. However, the information presented and selection of examples is not to be construed as an endorsement of 48 any particular product, nor is it intended to restrict health plan options to those in the selection. 50 [2] The College makes no warranty as to the availability of or acceptance for coverage by any health plan. 52 cost of that coverage up to the dollar subsidy that the College makes available under the qualified group health plan(s) to a 54 statutorily recognized spouse.[3] Contingent upon the dependent child of a domestic partner being 56 granted dependent equivalency status, and upon presentation of proof of having obtained individually issued health plan coverage 58 for the dependent, the College will reimburse the employee for the cost of that coverage up to the dollar subsidy that the 60 College makes available under the qualified group health plan(s) to a legal dependent.[4] 62 Reimbursement will be made on a monthly basis, regardless of the manner in which the premium is paid. 64 No reimbursement will be made for any month prior to the domestic partner's (and dependent of the partner) attaining 66 spousal/dependent equivalency status. CONDITIONS 68 This reimbursement plan is not available to an employee with a legal spouse covered under the qualified group health plan(s). --------------- 70 [3] The subsidy made available to a statutorily recognized spouse is the result obtained by subtracting the subsidy for 72 "employee-only" coverage from the subsidy for "employee plus one" (dependent) coverage. 74 [3] The subsidy made available to a legal dependent is the result obtained by subtracting the subsidy for "employee plus 76 one" coverage from the subsidy for "employee plus two or more" (dependents) coverage. 78 Reimbursement is limited to one spousal equivalent benefit, and if applicable, one dependent benefit, in any one month. 80 Any tax liability on the reimbursement is the responsibility of the employee. If required by federal and/or state regulations, 82 the College will comply with applicable withholding and reporting requirements. 84 Dependent equivalent status is contingent upon the domestic partner being maintained in spousal equivalent status. 86 It is the responsibility of the employee to notify the College of any change in the relationship. 88 Dependent equivalent status may be continued up to age 24 if the dependent is a full-time student. 90 This program is intended to benefit active employees of the College who elect and qualify for participation. The College has 92 no direct obligation to a domestic partner, or to the dependent of a domestic partner. 94 It is intended that this program will be continued indefinitely. However, the College reserves the right to modify or discontinue 96 this program at any time. This program is not available to former employees of the College. 98 Eligibility for active employees ends upon termination, regardless of reason for termination. 100 Qualification for a benefit under this program does not at this time confer eligibility under any other program sponsored by the 102 College. --- [This form and the information contained herein will be used exclusively for qualifying for benefits offered at Pitzer College and will not be released to any third party] PITZER COLLEGE APPLICATION FOR DOMESTIC PARTNERSHIP This application for domestic partnership is being made by an active Pitzer employee who is working on a regular schedule of half-time or more: We, the undersigned, do declare that: We are not related by blood; Neither of us is married, nor are we related by marriage; We share the common necessities of life; We are each other's domestic partner and have been each other's domestic partner since ________________; We are the sole domestic partner of each other and have no other domestic partners; We are both over 18 years of age; We are responsible for each other's welfare; We agree to notify the College of any change in the status of our domestic partnership agreement. I declare, under penalty of perjury, under the laws of the State of California, that the statements herein are true and correct. Executed on ___________________________________ , at ________________________________________________, California. _____________________________ _____________________________ Signature Signature _____________________________ ______________________________ Print Name Print Name _____________________________ ______________________________ Address Address _____________________________ ______________________________ City, State, Zip Code City, State, Zip Code _____________________________ ______________________________ (Area Code) Telephone (Area Code) Telephone WITNESS: ________________________________ Claremont College Representative