Event Sign In Sheet template - Saif
Employer verification form
TO BE COMPLETED BY THE SAIF EMPLOYEE’S DEPENDENT
I authorize my employer to release the information below regarding my access to health insurance.
SAIF employee’s name (print): __________________________________
Name of SAIF employee’s dependent (print) __________________________________
Signature of dependent ___________________________________ Date _______________
TO BE COMPLETED BY THE ABOVE LISTED DEPENDENT’S EMPLOYER
Dear employer,
Please assist us in reviewing your employee’s access to insurance coverage. Please check only one of the boxes below:
We do not offer group medical coverage to our employees, OR we offer group medical
coverage to our employees but this employee is not eligible because: ______________________________________________________________________
We offer group medical coverage to our employees and this employee is enrolled.
We offer group medical coverage to our employees and this employee declined coverage
because of the out-of-pocket premium cost under the employer’s least costly plan.
We offer group medical coverage to our employees and this employee opted out of this
coverage in order to receive cash or other benefits from the employer.
We offer premium-free group medical coverage to our employees and this employee
declined the coverage.
Employer representative signature ________________________________ Date ____________
Representative name (print) _______________________________ Title ___________________
Employer name ___________________________________ Phone ______________________
Address _________________________________ City ______________ State ___ Zip _______
Questions? Contact benefits@
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