Instructions

Step 1: Use the SEPA Calculator below to check your eligibility and discount.
Step 2: If eligible, complete the Enrollment Form and upload your documents.
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State Employee Premium Assistance

SEPA Enrollment Form

Personal Information

Contact Information

Household Information

Documentation Requirements

Income Documentation Requirements

State employees must submit proof of household income to be determined eligible for SEPA. The documents state employees submit to EASI Gov to confirm household income must show an income amount that closely matches the income amount reported to EASI Gov. For example, if someone in a household has a different job than last year, the state employee should send EASI Gov recent pay stubs from their new job, instead of last year's tax return or W2. Here are types of proof of household income that state employees can submit:

  • 1040 federal or state tax return. Must contain your first and last name, income amount, and tax year. If you file Schedule 1, you must submit it with your 1040.
  • Wages and tax statement (W-2 and/or 1099, including 1099 MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099SS, 1099INT). Must contain your first and last name, income amount, tax year, and employer name (if applicable).
  • Pay stub. Must contain your first and last name, income amount, and pay period or frequency of pay with the date of payment. If a pay stub includes overtime, tell us the average overtime amount per paycheck.
  • Self-employment ledger documentation (can be a Schedule C, the most recent quarterly or year-to-date profit and loss statement, or a self-employment ledger). Must contain your first and last name, company name, and income amount. If you're submitting a self-employment ledger, include the dates covered by the ledger, and the net income from profit/loss.
  • Social Security Administration Statements (Social Security Benefits Letter). Must contain first and last name, benefit amount, and frequency of pay.
  • Unemployment Benefits Letter. Must contain your first and last name, source/agency, benefits amount, and duration (start and end date, if applicable).

Allowable Income Standards

Employees can use the following measures of income to qualify for SEPA:

  1. The annual household income in the most recent available tax return.
  2. The monthly household income during the month before the employee submits a SEPA application.
  3. The projected annual household income during the upcoming benefits year with an attestation letter about household circumstances.

Types of Income That Must Be Reported

For 2025, SHB will use a household's adjusted gross income (AGI) as the standard for SEPA income determinations. AGI is your total gross income from all sources minus certain adjustments listed on Schedule 1 of Form 1040. Your AGI is calculated before you take your standard or itemized deduction on Form 1040.

For information about how to calculate AGI, visit IRS AGI Calculation Guide.

Reporting Household Changes

If a state employee who has been determined eligible for SEPA experiences a change that may impact SEPA eligibility, the employee must report these changes to EASI Gov as soon as possible. Changes that must be reported include:

  • Increases or decreases in household income
  • Adding a dependent to your household due to birth, adoption, foster care
  • Marriage or divorce
  • Death
  • You remove a dependent from your tax household for any reason other than adoption or foster care.

Knowingly Misreporting Income

If a state employee knowingly misreports income to gain access to SEPA or increase the amount of assistance they get, SHB may revoke future SEPA eligibility.

Terms and Conditions

When applying for State Employee Premium Assistance, I understand and agree to the following: