RES 2003-18 DOMESTIC PARTNER BENEFITSRESOLUTION 2003-18
A RESOLUTION of the City Council of the City of Bainbridge
Island, Washington, approving City Policy 400-012 designating
Domestic Partner Benefits.
WHEREAS, the City has long had a policy and an ordinance prohibiting discrimination
on the basis Of sexual orientation; and
WHEREAS, the Association of Washington Cities has recently extended medical
insurance an other benefits to the domestic partners of covered employees and their dependents;
and
H REAS, in order for the domestic partners and their dependents of the employees of
the CityWof ainbridge Island to be covered by the City's policy with the Association, the City
Council mu adopt by resolution a policy authorizing such coverage; now, therefore
THE CITY COUNCIL OF THE CITY OF BAINBRIDGE ISLAND,
WASHINGTON, DOES RESOLVE AS FOLLOWS:
The City Council of the City of Bainbridge Island, Washington adopts City Personnel
Policy 400-012 Domestic Partner Benefits, a copy of which is attached.
PASSED by the City Council this 9h day of April 2003.
APPROVED by the Mayor this 10'b day of April 2003.
Darlene Kordonowy,
ATTEST/
P. Kasper, City
FILED WITH THE CITY CLERK: March 21, 2003
PASSED By THE CITY COUNCIL: April 9, 2003
RESOLUTION NUMBER: 2003-18
The following is criteria establishing a domestic partner as eligible to enroll in the benefit
program purchased by the City of Bainbridge Island through the AWC Employee
Benefit rust:
• Sole relationship of same and opposite gender.
■ S1 iare the same regular and permanent residence; and
• H ave a close, personal and exclusive relationship; and
■ e jointly responsible for "basic living expenses," as defined below; and
■ e not married to anyone; and
• e each eighteen (18) years of age or older; and
• e not related by blood closer than would bar marriage in the State of
ashington;and
■ M ere mentally competent to consent to contract when the domestic partnership
began; and
• e responsible for each other's common welfare.
■ U on termination of a domestic partner relationship and termination of benefit
cc verage, a new domestic partner can be enrolled no earlier than 90 days
following termination of the prior relationship.
"Basic living expenses" means the cost of basic food, shelter and any other expenses of a
Domestic Partner, which are paid at least in part by a program or benefit for which the
partner qualified because of the Domestic Partnership. The individuals need not
contributeequally or jointly to the cost of these expenses as long as they agree that both
are resposible for the cost.
The follo ing is criteria establishing a domestic partner's dependents eligible to enroll in
the benefit programs purchased by the employer through the AWC Employee Benefit
Trust: 1
tural, adopted or court-appointed legal guardian of an unmarried child to age
The natural, adopted or court-appointed guardian may remain on the program
to age 23, if
A full-time student at an accredited institution (for medical, dental and vision
coverage); or
POLICY: DOMESTIC PARTNER BENEFITS PAGE 1 of 2
LABOR RELATIONS POLICY #400-012
APRIL 9, 200
ITY OF BAINBRIDGE ISLAND
DOMESTIC PARTNER BENEFITS
POLICY
LABOR
RELATIONS 400-012
EFFECTIVE DATE
APPROVED
April 9, 2003
The following is criteria establishing a domestic partner as eligible to enroll in the benefit
program purchased by the City of Bainbridge Island through the AWC Employee
Benefit rust:
• Sole relationship of same and opposite gender.
■ S1 iare the same regular and permanent residence; and
• H ave a close, personal and exclusive relationship; and
■ e jointly responsible for "basic living expenses," as defined below; and
■ e not married to anyone; and
• e each eighteen (18) years of age or older; and
• e not related by blood closer than would bar marriage in the State of
ashington;and
■ M ere mentally competent to consent to contract when the domestic partnership
began; and
• e responsible for each other's common welfare.
■ U on termination of a domestic partner relationship and termination of benefit
cc verage, a new domestic partner can be enrolled no earlier than 90 days
following termination of the prior relationship.
"Basic living expenses" means the cost of basic food, shelter and any other expenses of a
Domestic Partner, which are paid at least in part by a program or benefit for which the
partner qualified because of the Domestic Partnership. The individuals need not
contributeequally or jointly to the cost of these expenses as long as they agree that both
are resposible for the cost.
The follo ing is criteria establishing a domestic partner's dependents eligible to enroll in
the benefit programs purchased by the employer through the AWC Employee Benefit
Trust: 1
tural, adopted or court-appointed legal guardian of an unmarried child to age
The natural, adopted or court-appointed guardian may remain on the program
to age 23, if
A full-time student at an accredited institution (for medical, dental and vision
coverage); or
POLICY: DOMESTIC PARTNER BENEFITS PAGE 1 of 2
LABOR RELATIONS POLICY #400-012
APRIL 9, 200
nt upon the domestic partner for a majority of his/her support (for
;al coverage only).
lcapacitated children due to developmental disability or physical
are eligible beyond the age limit of the contract, provided the child is
-pendent on the domestic partner for support and maintenance, and the
occurred prior to the limiting age.
:NTS TO POLICY
of Marriage/Domestic Partnership
: of Termination of Marriage/Domestic Partnership
POLICY: DO ESTIC PARTNER BENEFITS PAGE 2 of 2
LABOR REL TIONS POLICY #400-012
APRIL 9, 2003
February 10, 2003
TO: AWC Employee Benefit Trust Member Employers
FROM: Paul Chasco, Assistant Director for Insurance Services
SUBJECT: DOMESTIC PARTNER COVERAGE
On November 21, 2002, the AWC Employee Benefit Trust Board of Trustees
approved domestic partners as an eligible dependent for enrollment in all benefit
programs (medical, dental, and vision). Enrollment of domestic partners and their
eligible children will remain a jurisdictional decision. An AWC Trust member
employer, who enrolls active employees in each benefit program, may choose to
adopt a personnel policy and/or negotiate a bargaining agreement identifying
domestic partners as an eligible dependent.
The Board felt adoption of a policy that extends Trust benefits to domestic partners
was a good business decision. However, the Board was clear in its direction that the
ultimate decision to extend coverage is the sole responsibility of each member's
governing body.
Effective April 1, 2003 the AWC Trust will offer a special open enrollment period
for those employers currently offering domestic partner benefits Attached is an
Affidavit of Marriage/Domestic Partnership Form for completion by those employees
wishing to enroll their domestic partner, and eligible children. A new Combined
Enrollment Form (revised form attached) should be completed by the employee and
accompany the Affidavit. The AWC will also need to receive a copy of the
employer's personnel policy and/or bargaining agreement addressing domestic
partner eligibility criteria.
Those jurisdictions adopting new domestic partner policies will be offered a special
open enrollment period the first of the month following policy adoption. A letter of
intent from the employer, along with the newly adopted policy, should be forwarded
to the AWC office.
Domestic Partner Criteria
The following is criteria establishing a domestic partner as eligible to enroll in the
benefit programs purchased by the employer through the AWC Employee Benefit
Trust:
Domestic Partner Memo
February 10, 2003
Page 2
■ Sole relationship of 1) same gender only; 2) opposite gender only; or 3) same
and opposite gender. (This criteria needs to be clarified by the employer in
the adopted policies.).
• Share the same regular and permanent residence; and
■ Have a close, personal and exclusive relationship; and
■ Are jointly responsible for "basic living expenses," as defined below; and
• Are not married to anyone; and
■ Are each eighteen (18) years of age or older; and
■ Are not related by blood closer than would bar marriage in the State of
Washington; and
■ Were mentally competent to consent to contract when the domestic
partnership began; and
■ Are responsible for each other's common welfare.
■ Upon termination of a domestic partner relationship and termination of benefit
coverage, a new domestic partner can be enrolled no earlier than 90 days
following termination of the prior relationship. (An employer may wish to
establish stricter criteria than 90 -day intervals. Such intervals should be
identified in the adopted policy, and noted on the Affidavit.)
"Basic living expenses" means the cost of basic food, shelter and any other expenses
of a Domestic Partner, which are paid at least in part by a program or benefit for
which the partner qualified because of the Domestic Partnership. The individuals
need not contribute equally or jointly to the cost of these expenses as long as they
agree that both are responsible for the cost.
Dependents of Domestic Partner Criteria
The following is criteria establishing a domestic partner's dependents eligible to
enroll in the benefit programs purchased by the employer through the AWC
Employee Benefit Trust:
■ Natural, adopted or court-appointed legal guardian of an unmarried child to
age 19. The natural, adopted or court-appointed guardian may remain on the
program up to age 23, if
■ A full-time student at an accredited institution (for medical, dental and
vision coverage); or
■ Reliant upon the domestic partner for a majority of his/her support (for
medical coverage only).
■ Totally incapacitated children due to developmental disability or physical
handicap are eligible beyond the age limit of the contract, provided the child is
chiefly dependent on the domestic partner for support and maintenance, and
the disability occurred prior to the limiting age.
Domestic Partner Memo
February 10, 2003
Page 3
If you have any questions regarding the newly adopted domestic partner policy,
please feel free to contact an AWC Trust staff member at 1-800-562-8981 or
benefitinfo(a)awcnet.org.
PC:CLW
Attachments
I,
CITY OF BAINBRIDGE ISLAND
.VIT OF MARRIAGE/DOMESTIC PARTNERSHIP
Name of Employee (Print)
A. I, and
OR
B. I, and
Name of Domestic Partner (Print)
certify that:
were legally married on
Date of Marriage
are domestic partners, and we:
1. share the same regular and permanent residence; and
2. have a close, personal and exclusive relationship; and
3. are jointly responsible for "basic living expenses," as defined below; and
4. are not married to anyone; and
5. are each eighteen (18) years of age or older; and
6. are not related by blood closer than would bar marriage in the State of Washington;
7. were mentally competent to consent to contract when our domestic partnership
began; and
8. are each other's sole domestic partner and are responsible for each other's common
"Basic livi g expenses" means the cost of basic food, shelter and any other expenses of a
Domestic I lartner which are paid at least in part by a program or benefit for which the partner
qualified because of the Domestic Partnership. The individuals need not contribute equally or
jointly to tile cost of these expenses as long as they agree that both are responsible for the cost.
A. I under$tand that this affidavit shall be terminated upon the death of my spouse/domestic
partner for by a change of circumstance attested to in this affidavit.
I agree to notify Human Resources if there is any change of circumstances attested to in this
affidav t within thirty (30) days of change by filing a Statement of Termination of
Marriage/Domestic Partnership.
B. Afters such termination, I understand that another Affidavit of Marriage/Domestic
Partner hip cannot be filed until ninety (90) days after a Statement of Termination of
Mama e/Domestic Partnership has been filed with Human Resources, unless such
is due to the death of my spouse/domestic partner, or the dissolution of my
VIT OF MARRIAGE/DOMESTIC PARTNERSHIP
I have comple ed the AWC Combined Enrollment Form enrolling my domestic partner in the
benefit prograris available, to be effective no sooner than the first of the month following date of
eligibility (refer to Section I for domestic partner eligibility).
If applicable, I have completed the AWC Combined Enrollment Form enrolling my natural
children, adopted children, or court-appointed guardians. Additionally, if applicable, I have
completed the AWC Combined Enrollment Form enrolling the natural children, adopted children,
or court-appoi ited guardians of my domestic partner. Additional criteria for eligible dependent
children is as ollows:
adopted or court-appointed legal guardian of an unmarried child to age 19. The
adopted or court-appointed guardian may remain on the program up to age 23, if:
■ A hull -time student at an accredited institution; or
upon the employee or domestic partner for a majority of his/her support.
Totall incapacitated children due to developmental disability or physical handicap are
eligibl beyond the age limit of the contract, provided the child is chiefly dependent on the
emplo ee or domestic partner for support and maintenance, and the disability occurred prior
to the 1 miting age.
The coverage tffective date for my domestic partner and, if applicable, the children of my domestic
partner, is
Effective Date (Print)
I understand that additional income will be reported in my name to the Internal Revenue Service,
and that applicable taxes will be withheld, for the premiums paid for the coverage for the enrolled
domestic partner and their eligible, enrolled children. An exception will be made when IRS has
ruled that the domestic partner is reliant upon the employee for support and is an eligible dependent.
(NOTE: Supporting IRS documentation will be provided to Human Resources, along with the
signing of thisdocument.)
Name (Please Print) Date
Signature
Social Security Number
I,
CITY OF BAINBRIDGE ISLAND
STATEMENT OF TERMINATION OF
MARRIAGE/DOMESTIC PARTNERSHIP
Name of Employee (Print)
affirm, under penalty of perjury, that the
Affidavit of Marriage/Domestic Partnership attested to and signed by me on
Date of Affidavit
Shall be and is terminated as of this date.
Termination Of Affidavit of Marriage/Domestic Partnership is due to:
❑ Dissc lution of Marriage
❑ Term ination of Domestic Partnership
❑ Death of Spouse/Domestic Partner
I understand hat another Affidavit of Marriage/Domestic Partnership cannot be filed until ninety
(90) days aft4 r this Statement of Termination of Marriage/Domestic Partnership has been filed
with Human Zesources, unless such termination is due to the death of my spouse/domestic
partner, or th dissolution of my marriage.
I understand Itat my former spouse/domestic partner (and former spouse/domestic partner's dis-
enrolled children, if applicable) may have COBRA Continuation Coverage rights. I shall mail a
copy of this signed statement to my surviving former spouse/domestic partner.
Name (Please p int) Date
Signature
Social Security Number