Form Gr-67618 - New Jersey Small Employer Health Benefits Waiver Of Coverage - Aetna
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1New Jersey Small Employer Health Benefits
Waiver of Coverage
Employer Information
Group Policy Number
Policyholder Name
Employee Information
Name (Last, First, Middle Initial)
Social Security Number
Marital Status
Date of Employment
Date of Birth (MM/DD/YYYY)
Single
Married
Widowed
Divorced
Refusal (Please check the appropriate box.)
I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by Aetna,
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 Group Health Plan sponsored by this employer
Other Group Health Plan sponsored by another organization
Other Group Health Plan sponsored by my spouse’s employer
Other reasons (please explain)
Please identify Group Health Plan(s) and provide name(s) of Policyholder(s), carrier(s) and policy number(s)
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 the marriage, birth, adoption, or placement for adoption.
If the reason for 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 Pre-Existing Condition Statement), and coverage may be subject to a pre-existing conditions exclusion.
Signature of Employee
Date (MM/DD/YYYY)
Signature of Witness
Date (MM/DD/YYYY)
GR-67618 (5-05)
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