Health Insurance Opt Out Bonus Form

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
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.
2 + 2 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.