Form 2465 (W1004) - Small Employer Member Waiver Of Coverage Form
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1SMALL EMPLOYER HEALTH BENEFITS WAIVER OF COVERAGE
Group Policy No.: ___________________
Policyholder Name: ______________________________________________________________________________________
Employee Name: _________________________________________________ Social Security #: _________________________
Last
First
MI
Marital Status:
Single
Married
Widowed
Divorced
Date of Employment: ____________________________________ Date of Birth: ____________________________________
I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by Horizon
Blue Cross Blue Shield of New Jersey, Inc. I refuse the following:
Employee, Spouse, and Child(ren) coverage
Spouse coverage
Child(ren) coverage
Reason for Refusal (Please check all appropriate boxes.)
other fully-insured Group Health Plan sponsored by this employer
other Group Health Plan sponsored by my spouse’s employer
other group coverage sponsored by another organization
covered under Medicare
other reasons (please explain) ___________________________________________________________________________
Please identify Group Health Plan(s) and provide names(s) of Policyholder(s), carrier(s) and policy number(s).
Policyholder/Name: ________________________________________________________________________________
Carrier: _____________________________________________________ Policy number: ________________________
Policyholder/Name: ________________________________________________________________________________
Carrier: _____________________________________________________ Policy number: ________________________
Policyholder/Name: ________________________________________________________________________________
Carrier: _____________________________________________________ Policy number: ________________________
If you are declining enrollment for yourself or your dependents (including your spouse) because of other Group Health Plan coverage,
you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after
your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption,
you may be able to enroll yourself and your dependents provided, that you request enrollment within 30 days after marriage, birth,
adoption or placement for adoption.
If the reason for the refusal of coverage is coverage under another Group Health Plan, it is important to provide information concerning
that Group Health Plan on this Waiver of Coverage form. If you fail to provide this information on this Waiver of Coverage form and you
later become ineligible for such other coverage and then wish to enroll in any of the refused coverages, you will be considered a Late
Enrollee and may be subject to the pre-existing conditions exclusion.
I understand that if I later wish to enroll for any of the coverage(s) refused, I will be required to submit an Enrollment Form and coverage
may be subject to a pre-existing conditions exclusion.
__________________________________________________________
_______________________________
Signature of Employee
Date
__________________________________________________________
_______________________________
Signature of Witness
Date
An Independent Licensee of the Blue Cross and Blue Shield Association
2465 (W1004)
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Parent category: Medical