Spouse Employer Insurance Verification Form
Employee Information
Employee Name
Employee ID
Employee Phone
Employee Department
Spouse Information
Spouse Name
Spouse Date of Birth
Spouse Employer Name
Spouse Employer Phone
Insurance Information
Medical Coverage Offered
Medical Coverage NOT Offered
Insurance Carrier Name
Group Number
Policy Number
Coverage Effective Date
Coverage Termination Date (if applicable)
Employer Verification
Employer Representative Name
Employer Representative Title
Employer Representative Email
Employer Representative Phone
Employer Representative Signature
Date