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Spouse's/RDP's Employer's Certification II: Employer Coverage
BSSP Covered Employee: __________________________________________
BSSP Covered Employee's Spouse/RDP (your employee): _____________________________
I hereby certify that the person listed as Spouse/RDP, above, is covered under his/her employer's medical and prescription benefit plan effective _____________________________; carrier: ____________________; carrier address: ________________________________________; employee benefit ID number: ________________________.
__________________________________ __________________________________ (printed name) __________________________________ __________________________________