Health Insurance Opt Out Bonus Form

Employer's phone number
I authorize Sparrow's Human Resources Department to contact the insurance company and/or employer listed above for the purpose of confirming my coverage in another plan.
CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
12 + 1 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.