Primary SpouseSaver Enrollee

(Primary Enrollee is either the employee if they have enrolled in the SpouseSaver or the Spouse if the employee has maintained enrollment on their employer plan.)

First Name *

Last Name *

Phone *

Email *

Enrollee Member ID *

Primary Enrollee Address

(Primary Enrollee is either the employee if they have enrolled in the SpouseSaver or the Spouse if the employee has maintained enrollment on their employer plan.)

Address *

City *

Postal code *

State *

Is the "Primary Enrollee" the spouse of the employee? (Primary Enrollee is either the employee if they have enrolled in the SpouseSaver or the Spouse if the employee has maintained enrollment on their employer plan.)

*

Yes

No

Spouse First Name *

Spouse Last Name *

Spouse Date of Birth *

Spouse SSN *

Spouse Phone *

Spouse Email *

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

Yes

No

Spouse Street Address *

Spouse City *

Spouse Zip Code *

Spouse 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.

Summary of Benefits Coverage Example

*

Upload Supporting Documents Here

How many Dependents do you have? *

Dependent First Name *

Dependent Last Name *

Dependent Date of Birth *

Dependent SSN *

Dependent First Name *

Dependent Last Name *

Dependent Date of Birth *

Dependent SSN *

Dependent First Name *

Dependent Last Name *

Dependent Date of Birth *

Dependent SSN *

Dependent First Name *

Dependent Last Name *

Dependent Date of Birth *

Dependent SSN *

Dependent First Name *

Dependent Last Name *

Dependent Date of Birth *

Dependent SSN *

Dependent First Name *

Dependent Last Name *

Dependent Date of Birth *

Dependent SSN *

Dependent First Name *

Dependent Last Name *

Dependent Date of Birth *

Dependent SSN *

Are you ready to add payroll details? *

Payroll Deduction Details

Is there a 3rd Payroll Deduction? (If there is a 3rd pay period in the month, are premium deductions taken out?) *

Yes

No

Health Insurance Premium (Per Pay Period Amount) *

$

Supporting Health Insurance Premium Documentation *

Upload Supporting Documents Here

Example Paystub

By electing Spouse Saver, I certify that:

I and/or my spouse and/or m 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 Spouse Saver.
The alternate group medical plan does not and will not consist solely of "expected 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 Spouse Saver, 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 Spouse Saver. All members may use the HSA funds for dental and/or vision as long as those expenses are not covered by Spouse Saver.
- Medicare, Tricare, Medicaid or another governmental program
- Health Insurance Coverage made available thru the Affordable Care Act
- Individual Policy
- Limited Benefit Health Plans
- Another medical plan

Yes, I agree

Signer Name *

Signature *

Clear

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