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Archdiocese of St. Louis Health Insurance Plan
Spousal Surcharge Exemption Form

A spousal surcharge of $125 per month will be automatically deducted from your pay by your employer, if you cover your spouse in the Archdiocesan Health Insurance Plan.  If you meet the eligibility (see Employee Attestation below) for an exemption from the $125 monthly spousal surcharge, submit this online Spousal Surcharge Exemption Form and return it to your benefits administrator, no later than 31 days from the date of health insurance eligibility. Your lack of response or incomplete information could impact your payroll deductions. A spousal surcharge is an extra charge to an employee for insuring a spouse who has coverage available through his/her own employer.

Online submission of this form is preferred yet a printed copy of it can be submitted by mail, fax or email. To print a copy of this form Click Here. Please view contact information at bottom of form.

Employee Information

Employee Attestation: I am exempt from the spousal surcharge due to the following reason (select one circle).

Employee Acknowledgement




For Questions:

Archdiocese of St. Louis
Office of Human Resources

20 Archbishop May Drive | St. Louis, MO 63119
Phone: 314.792.7546 | Fax: 314.792.7548
Email: | Internet:
Your employer's benefits administrator

Online submission of this form is preferred,
but a printed copy of it can be submitted by mail, fax or email.

Copyright 2018 by Archdiocese of St. Louis