When opening the Health Insurance Opt Out form in Internet Explorer you will receive an unsupported browser message. The form still functions in Internet Explorer, you can close out of the error message and continue completing the form. If you’d prefer, please copy this link and paste into the internet browser of your choosing: https://www.sparrow.org/health-insurance-opt-out-bonus-form Name First Last Caregiver Number Name of other health insurance plan Insurance group number Insurance contract number Name of subscriber Subscriber's employer Employer's phone number Phone Ext: Yes, I agree 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. Math question 5 + 2 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. Leave this field blank
