Note: This form is completed when there is an "Addition" or "Removal" of a Spouse and/or Dependent(s) to your Employer Benefits Plans.
** Indicates Required Fields.
if further instruction is needed.
Note: When entering spouse and/or dependent(s) information, you MUST under DOL/IRS Rules enter their Full SSN and DOB. If this information is not provided, we CANNOT process claims for a spouse and/or dependent(s) under the Rules of the IRS.
Note: For an additional debit card for a Spouse and/or Dependent(s). Please contact IntegraFlex Customer Service to request additional cards. Dependents MUST be 18 years of age for debit card eligibility.
Note: Please provide us with your best contact number and email address, so we may contact you regarding your account, if needed.
Date of Signature