Attachment 4 - Technical Exhibit Affidavit of Domestic Partnership.doc
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- Attached to
- Group Life Insurance
- Solicitation number
- 2031JW21Q00092
About this file
This document contains an attachment to a request for quotation for an OCC group life insurance program. The OCC and OFR are seeking an experienced contractor to underwrite and administer their group life insurance programs for approximately 2,580 active employees, 2,510 retirees, and eligible dependents. The program currently provides term life insurance through a policy set to expire on June 30, 2021. The contractor will be required to amend the existing policy to incorporate the addition of former OTS employees and OFR employees and dependents per the Dodd-Frank Act. Coverage for supplemental or optional employee insurance will be available from $25,000 up to $500,000 or 5 times salary. Enrollment changes due to salary increases can be made within 31 days for up to $50,000 in additional coverage. The current administrator is Metropolitan Life.
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Attachment 4 - Technical Exhibit Affidavit of Domestic Partnership
RFQ: 2031JW21Q00092
Affidavit of Domestic Partnership Section 1: Domestic Partner Statement
The undersigned, being duly sworn, depose and declare as follows:
We are each eighteen years of age or older and mentally competent.
We are not related by blood in a manner that would bar marriage under the laws of the State of .
We have a close and committed personal relationship, and we are each other’s sole domestic partner not married or partnered with any other spouse, spouse equivalent or domestic partner.
For at least six months we have shared the same regular and permanent residence in a committed relationship and intend to do so indefinitely.
Section 2: Domestic Partner Signatures
Each of us agrees to notify the OCC if there is any change in our status as domestic partners as attested to in this Affidavit.
Each of us understands and agrees that in the event any of the statements set forth herein are not true, the relocation benefits for which this Affidavit is being submitted may be rescinded and/or each of us shall jointly and severally be liable for repayment of relocation expenses reimbursed by the employer.
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RFQ: 2031JW21Q00092
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Print name Print name file_2.wmf
RFQ: 2031JW21Q00092
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Signature Signature Section 3: Notary Public Acknowledgment
The foregoing document was acknowledged before me this day of
, 20 by .
Notary Public
File details come from the government source that posted it. Updated .