Instructions
• Complete the enrollment & group coverage details eform as soon as you are able to by clicking on "Submit Coverage Details" below.
• Note: If you don’t have access to payroll details initially, please submit the additional supporting documentation for premium amounts once available by clicking on "Submit Payroll Details" below.
Spousal Incentive HRA Enrollment Forms
Enrollment & Group Coverage Details
Finish setting up your account by completing the coverage form online. To complete this form, you'll need to provide:
Proof of enrollment in alternate coverage
Pay statement to show proof of alternate coverage premium amounts and frequency
Copy of alternate plan's Summary Plan
Descriptions showing deductible amounts and out-of-pocket maximums.
Payroll Details
To complete the Spousal Incentive HRA enrollment, your spouse is required to;
Provide Premium payment verification from employer
- A paystub showing the premium contribution amount, pre-tax or post-tax and frequency (other information may be blacked out)
