Form Ha-0780 - State Employee Coverage Waiver/reinstatement printable pdf download

State Health Beneﬁ ts Program (SHBP)

STATE EMPLOYEE GROUP

STATE EMPLOYEE COVERAGE WAIVER/REINSTATEMENT FORM

Part 1: To be completed by the employee. Please print.

Name _____________________________________________________________ SS# __________________________

Check one box below.



Waiver of Coverage

I agree to voluntarily waive State Health Beneﬁ ts Program (SHBP) coverage to which I am entitled because I am covered

under other health coverage. I understand that while coverage is waived, I will not be required to make payroll contributions

required for medical and/or prescription drug coverage.

I understand that I may resume State Health Beneﬁ ts Program coverage if I lose coverage under the other health coverage,

provided that I notify the SHBP within 60 days of the loss of the other coverage and provide proof of loss of that coverage.



Reinstatement of Coverage

I previously waived State Health Beneﬁ ts Program coverage because I had other health coverage. As of _____/_____/_____,

I am no longer covered by the other health plan, request reinstatement of the State Health Beneﬁ ts Program coverage, and

have provided proof of loss of the other coverage. I further understand that coverage is permitted as an employee, retiree,

or dependent; however, multiple coverage under the State Health Beneﬁ ts Program is prohibited.

Employee’s Signature _______________________________________________________

Date _____/_____/_____

Part 2: To be completed by the employer. Check one box below.



e understand that this employee is requesting to voluntarily waive State Health Beneﬁ ts Program coverage.



We request reinstatement of this employee’s State Health Beneﬁ ts Program coverage.

A completed State Health Beneﬁ ts Program Application must be attached to either a waiver or a reinstatement.

The reinstatement application must be ﬁ led within 60 days of the loss of other health coverage. If this timetable is followed,

the coverage will be retroactive to the date of loss. If the 60 day time limit has passed, the employee must wait until the next

open enrollment period to reenroll.

Employer Name _________________________________________ SHBP Location # ____________________________

Signature of Certifying Ofﬁ cer ___________________________________________________ Date _____/_____/_____

New Jersey Division of Pensions & Beneﬁ ts (NJDPB)

Health Beneﬁ ts Bureau

P.O. Box 299

Trenton, NJ 08625-0299

Form Ha-0780 - State Employee Coverage Waiver/reinstatement