hsa benefits

Sample Agreement to Pay Insurance Premiums

[DATE]

To: Employee Name

From: Management/Company

RE: Agreement to Pay Insurance Premiums during Furlough

Dear (employee name),

Below is confirmation of your agreement to pay the employee portion of the insurance premium cost for the continuation of your benefits coverage during the furlough period. 

I, the undersigned, agree to pay $(insert amount) on or before the (insert day of a month) of each month for the continuation of (insert benefit) coverage. [insert instructions on who and where to send payment]

I further agree that should I fail to make payment in full on or before the agreed-upon date, I risk cancelation of coverage.

I understand that if I have any questions or concerns, I should contact Human Resources for clarification.               

Employee Name (Print)     

Employee signature                                                  Date           

Company representative (signature)                         Title         

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