Request for Verification of Insurance Form

**There is a two-day waiting period for all Verifications of Insurance**

I hereby authorize Hendrick HR Benefits to release information regarding my insurance plan(s).

Please note: If you are moving into an ineligible status (resigning or status change), HR cannot process your request until an official notice has been sent to HR.

Click here to access the Benefits Guide

Questions? Contact HR Benefits at benefits@hendrickhealth.org or call 325-670-3163

Employee ID

Employee First Name

Employee Last Name

Preferred Email

Preferred Phone Number

Information to Release

Please indicate the appropriate information you would like for us to release (select all that apply).

*If premium breakdown is selected, please complete the next question.

Premium Breakdown

If premium breakdown is requested, is the request for a specific person? If so, please list in the comment box/explain request.

Delivery Method

Email is our default delivery method. If you prefer an alternate method please list in the comment box.

Employee Authorization

Employee Signature

My electronic signature is the same as my written signature.

Type your first and last name as your electronic signature.

Confirmation

We highly recommend checking the box "Send me a copy of my responses" for confirmation your submission was successful.

Send me a copy of my responses

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