Insurance Substantiation Form

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Lake Superior School District
INTEGRATED HEALTH REIMBURSEMENT ACCOUNT
INSURANCE SUBSTANTIATION FORM
Instructions: Completion required only when enrolling in the Integrated HRA Plan
ISD #381employee, have your spouse take this form to his/her employer for
completion. Submit this form along with the Enrollment form.
Dear Employer,
Your employee’s spouse is being offered the opportunity to participate in an employer sponsored
Integrated HRA Plan. This will allow them to submit incurred out-of pocket medical, dental and
vision expenses for reimbursement. The criteria for plan eligibility is the Lake Superior School
District employee must provide proof they have group health insurance coverage under your
employer plan. This form was created to simplify and expedite the substantiation process.
Please fill out the form and return it to your employee. Thank you for your cooperation. If you
have questions, please call (800-447-1690).
Compensation Consultants, Ltd.
P.O. Box 720
Cloquet, MN 55720
Your Company’s Name:__________________________________________________
Your Company’s Address:________________________________________________
Your Company Phone Number:____________________________________________
Your Employee’s Name:_______
___________________________________________________
(please print)
Your Employee Spouse’s Name:
____________________________________________________
(please print)
Does Your Employee’s Spouse Have Health Insurance Coverage Under Your Company’s
 Yes  No
Employer Sponsored Health Plan?
Is your Health Plan a High Deductible Health Plan and contributions are made to a Health
 Yes  No
Savings Account (HSA)?
AFFIRMATION:
To the best of my knowledge and belief, my statement in this request for health insurance
coverage substantiation is accurate and true.
Employer Signature:
_______________________________________
Title:_____________________________________________
Date: ________/ _______/ ______
201405

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