Form Bn0139-0216 - Decline Coverage Acknowledgement Form printable pdf download

DECLINE COVERAGE ACKNOWLEDGEMENT FORM

YOUR Costco Employee #______________

CHECK THE BOX THAT APPLIES TO YOU

DECLINE HEALTH COVERAGE – COVERED AS THE DEPENDENT OF ANOTHER COSTCO EMPLOYEE

I am a benefit eligible Costco employee who qualifies and is enrolled in health coverage as a dependent of another benefit

eligible Costco Employee:

I am covered under Costco Employee # ________________. Their name is __________________________________



I will receive health coverage as elected by the above employee.

I will receive Basic Life, AD&D, and Long Term Disability Insurance.



I may elect to participate in the Health Care Reimbursement Account and Dependent Care Assistance Plan, as well



as Supplemental Life Insurance and Supplemental AD&D Insurance. I must elect these benefits according to the

rules and time periods described in the SPD for the Costco Employee Benefits Program.

DECLINE HEALTH COVERAGE - COVERED UNDER ANOTHER PLAN

I decline coverage under Costco’s Health plans and elect to pay for Long Term Disability plan coverage. Premiums for LTD

coverage will be withheld from my wages on a pre-tax basis.

I authorize Costco to deduct the premiums for this benefit from my wages on a pre-tax basis. The premium is $10.00



per pay period if hired before 1/1/13 or $13.00 per pay period if hired on or after 1/1/13.

I will receive Basic Life Insurance and Basic Accidental Death and Dismemberment Insurance coverage.



I may elect to participate in the Health Care Reimbursement Account and Dependent Care Assistance Plan, as well

as Supplemental Life Insurance and Supplemental AD&D Insurance. I must elect these benefits according to the

rules and time periods described in the SPD for the Costco Benefits Program.

DECLINE HEALTH COVERAGE - ALL COVERAGE

I decline all Program coverage.



I will not have any coverage under the Program for Health Care, Life Insurance, AD&D Insurance or Long Term

Disability Insurance.



I may not elect to contribute to the Health Care Reimbursement Account or Dependent Care Assistance Plan.

I may not change the benefit elections on this form until the next annual Open Enrollment, unless I experience a



qualified change in status (as defined by the Program)

I understand that this election does not apply to Voluntary Short Term Disability (VSTD). VSTD has different eligibility rules

and enrollment periods. When I become eligible for VSTD, I will be automatically enrolled and if I choose to decline coverage I

must make my election on the Enrollment Website or by calling the Enrollment Center within the enrollment period associated

with my VSTD eligibility date.

I have read the Summary Plan Description and Enrollment Materials for the Costco Employee Benefits Program and I

understand my rights to benefits under the Program. I hereby knowingly and voluntarily elect to decline coverage under the

Program as designated herein. I have had sufficient time to consider this waiver and I agree that I will not hold Costco or the

Program responsible if it turns out that declining coverage under the Program was not to my advantage.

________________________________________

________________________________

Employee Name (Printed)

Employee Number

________________________________________

________________________________

Employee Signature

Date

BN0139-0216

DECLINE COVERAGE ACKNOWLEDGEMENT FORM

Form Bn0139-0216 - Decline Coverage Acknowledgement Form

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