Add or Remove Spouse and/or Dependent(s)

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.

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Employer Information

Company Name**

Employee Information

First Name**

M.I.

Last Name**

Social Security Number**

Date of Birth**

Email address**

Spouse/Dependent(s) Information

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.

Add/Remove Spouse**

Yes

List any disabled dependents

Notes

Type Full Signature**

Date of Signature

This field should be left blank

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