This form is required when an employee and spouse employed by different districts/entities wish to end a Split Billing arrangement that is currently in place. Filling out and submitting this form authorizes that the employee has authorized his or her Benefits Administrator to complete this application and that he or she understand the terms of the Split Premium process. This application for Split Billing arrangement termination is for billing purposes only. All enrollments must be completed by way of the standard enrollment process separately from this application, if necessary.