Waiver Of Health Insurance And Cash In Lieu Election Form printable pdf download

Election or Waiver of Health Insurance

(Premium Contribution or Cash in Lieu)

Employee: ____________________________________________________________________________

Last,

First

Middle Initial

Address: ____________________________________________________________________________

Street

Apt #

______________________________________________________________________________________________________

City

State

ZIP

Date of Birth:

____ / ____ / _______

Social Security number: ________ - ______ - ________

I elect to receive Oak Park School District (“OPSD”) medical insurance. By doing so, I agree to complete

enrollment forms within 30 days of hire. I further elect to reduce my salary on a pre-tax basis to pay

my required share of insurance premiums. This amount will be deducted on a regular basis through

normal payroll beginning with the designated plan year.

I waive receiving OPSD medical insurance. By doing so, I will receive additional, taxable compensation

(cash in lieu). This amount will be determined under the applicable collective agreement/individual

contract, and paid to me on my normal payroll schedule.

To be eligible for cash in lieu, I must first provide proof of other qualifying group medical insurance for

myself and each member of my expected tax family (all individuals on my tax return). A copy of an

insurance card is not acceptable (although Canadian citizens may provide a copy of the OHIP card).

Proof is an official document verifying insurance under a group health insurance plan. For example, a

letter or official website document from your spouse’s employer stating your family is currently

covered under its health insurance plan, and which lists your family members’ names as eligible

dependents.

Your other medical coverage cannot be government-provided insurance (e.g., Medicare, Medicaid,

Tricare, VA, MIChild), COBRA, or any plan purchased as an individual, including those purchased

through the Health Insurance Marketplace.

I refuse to enroll myself in any type of medical coverage at this time, and I am aware of the possible

consequences under the ACA. By declining affordable coverage, I will not receive Marketplace

premium subsidies, nor will I receive cash in lieu.

I acknowledge:

1. My election can’t be changed during the plan year, unless for a qualifying event.

2. My next opportunity to obtain coverage will be during the Annual Open Enrollment period.

If I declined coverage, I will not be eligible for COBRA continuation if my employment ends during the period of

coverage I have declined.

_______________________________________________

_________________________

Employee Signature

Date

Waiver Of Health Insurance And Cash In Lieu Election Form

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