Primary Spousal Incentive HRA Enrollee

Primary enrollee is the Watco team member if they are enrolling for themselves. If the Watco team member plans to enroll in a Watco health plan but is enrolling their spouse/family in the Spousal Incentive HRA plan, then the primary enrollee listed below must be the spouse.

First Name *

Last Name *

Phone *

Email *

Primary Enrollee Address

Primary Enrollee is the Watco team member if they have enrolled in the Spousal Incentive HRA plan for themselves. If the Watco team member is staying enrolled in the Watco plan but enrolling their spouse/family in the Spousal Incentive HRA plan, then the Primary Enrollee listed below will need to be the spouse.

Address *

City *

Zip Code *

State *

Is the information you just provided the spouse of the Watco team member? *

Yes

No

Spouse's First Name

Spouse's Last Name

Spouse's Date of Birth

Spouse's SSN

Spouse's Phone

Spouse's Email

Is the spouse's address different from the previously provided primary address? *

Yes

No

Spouse's Street Address *

Spouse's City *

Spouse's Zip Code *

Spouse's State *

Coverage Type *

Insurance Plan Type *

In-Network Out-of-Pocket Max *

$

Please Upload a Copy of Your "Benefits Guide" or Other Supporting Documentation Showing Coverage Fees For Your Alternative Group Coverage. Attached Document Must Include In-Network Out-Of-Pocket Max Amount. *

Upload Supporting Documents Here

Other Than Your Spouse, How Many Dependents Do You Have? *

Dependent's First Name *

Dependent's Last Name *

Dependent's Date of Birth *

Dependent's SSN *

Dependent's First Name *

Dependent's Last Name *

Dependent's Date of Birth *

Dependent's SSN *

Dependent's First Name *

Dependent's Last Name *

Dependent's Date of Birth *

Dependent's SSN *

Dependent's First Name *

Dependent's Last Name *

Dependent's Date of Birth *

Dependent's SSN *

Dependent's First Name *

Dependent's Last Name *

Dependent's Date of Birth *

Dependent's SSN *

Dependent's First Name *

Dependent's Last Name *

Dependent's Date of Birth *

Dependent's SSN *

Dependent's First Name *

Dependent's Last Name *

Dependent's Date of Birth *

Dependent's SSN *

Are you ready to add payroll details? *

Note: If you do not have your payroll details, once you have access to them, please submit them through the Spousal Incentive HRA portal. Click on "Benefit Details" and then click on "Add Payroll Details."

Payroll Deduction Details

Are premiums deducted when a month has a third pay period? *

Yes

No

Payroll Deduction Frequency *

12 (Monthly)

16 (Monthly but with third payroll deductions included)

24 (Semi-Monthly, either 15th & last day of the month or 1st and 15th)

26 (BiWeekly)

52 (Weekly)

Per Pay Period Amount *

$

Supporting Health Insurance Premium Documentation

Upload Supporting Documents Here

Example Paystub

By electing the Spousal Incentive HRA, I certify that:

I and/or my spouse and/or my eligible dependents will be enrolled in an “alternate group medical plan” (such as my spouse’s employer) at all times while I/we are enrolled in the Spousal Incentive HRA.
The alternate group medical plan does not and will not consist solely of “excepted benefits” (such as limited-scope dental or vision coverage or other limited coverage).
The alternate group medical plan is not solely an account that reimburses health care expenses up to a dollar limit, like an FSA or HRA.
The alternate group medical plan is not:
- High Deductible Health Plan (HDHP) with active contributions to a health savings account (HSA); however, as long as my spouse is not enrolled in the Spousal Incentive HRA, my spouse may contribute to an HSA and use the HSA funds. The HSA funds CANNOT be used for medical expenses for members enrolled in the Spousal Incentive HRA. All members may use the HSA funds for dental and/or vision as long as those expenses are not covered by the Spousal Incentive HRA.
- Medicare, Tricare, Medicaid or another governmental program
- Health Insurance Coverage made available through the Affordable Care Act
- Individual Policy
- Limited Benefit Health Plans
- Another Watco medical plan

Yes, I Agree

Signer's Name *

Signature *

Clear

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