Please use the complete name of your congregation
Please enter the last four digits of your account number. This number can be found at the top left center of your invoice.
Please enter the email address of the person completing this form. It will only be used to send a confirmation message and to contact you if we have any questions about your form.
Entering your name here serves as verification that this information is true and correct to the best of your knowledge.
If you are on COBRA or self employed, please check here and fill in only the Employee Contribution.
Enter the first and last name of the first employee on your invoice who is enrolled in the Health Plan.
Enter the total amount of the monthly premium paid by the Congregation for Employee 1
Enter the full amount of monthly premium paid by Employee 1. Please enter 0 if the employer paid the full premium.
Enter the total contribution. This should equal the premium amount on your invoice.