Waiver Of Medical Coverage Form

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Waiver of Medical Coverage
(This sworn statement must be completed each November during Open Enrollment.)
Name: _____________________________________
Employee ID: _______________________
Last
First
M.I.
Campus Address: ____________________________
Work Phone: ________________________
Name of Spouse: _____________________________
Check here if your spouse or civil union partner is an employee of UVM.
Check here if you are employed by and have medical coverage through UVMMC.
Name and Age of Other Dependents: ____________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Employer (other than UVM) providing group health coverage: _________________________________
Insurance Carrier for other group health coverage: _________________________________________
Provide a photocopy of your group ID card or other evidence of medical insurance coverage.
I hereby elect to receive $1,000* in lieu of coverage under the University of Vermont’s group health plan
and swear that all of my dependents and I are covered by the group health coverage described above
and we hereby waive our health coverage under the University of Vermont’s group health plan. I
understand that I will not be allowed to change this election until the next annual open enrollment
unless there is a change in my family status as defined by the IRS and described in the FSA Summary
Plan Description. Any future change request tied to a change in family status must be made within 20
days of losing medical coverage with my insurance carrier. I acknowledge that my waiver of medical
coverage will be paid to me on a prorated basis** based on the number of paychecks I receive during
the calendar year.
Those waving coverage may continue to do so by completing a new Waiver of Medical Coverage. This
must be done annually in order to receive the $1,000 waiver reimbursement. An employee whose
spouse or civil union partner works at the University is not eligible for this waiver of medical coverage.
Sworn Signature: __________________________________
Date: ________________________
* You are not eligible for the $1,000 waiver if any one of the following is true:
 your spouse is also an employee of the University of Vermont
 you or your dependents have Medicare or Medicaid
 you or your dependents are on COBRA
 you or your dependents have an individual plan
 you are employed by and have medical coverage through
UV
** The $1,000 waiver is prorated based on the length of time actually employed during the calendar year.

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