Waiver Of Group Health Insurance Coverage (Page 2 of 2) in pdf

Waiver Of Group Health Insurance Coverage Page 2

INSTRUCTIONS FOR

COMPLETING WAIVER

The information below shows the sections of the form that must be completed and describes the type of information needed to process your Waiver of Coverage. A waiver form must be completed when

the applicant and/or spouse and/or any eligible dependent does not enroll for health insurance products offered by the employer.

1. APPLICANT INFORMATION

Print clearly your name, your Social Security Number, and if applicable, your spouse's name and your spouse's Social Security Number.

2. VALIDATION STATEMENT

Check "Employee Coverage" if coverage is being waived by the employee on behalf of self for one or more types of coverages. Check "Spouse Coverage" if coverage is being waived on behalf of the

spouse. Check "Other Eligible Dependent Coverage" if coverage is being waived on behalf of other eligible dependent(s).

3. OTHER INSURANCE INFORMATION

Complete this section if you and/or your spouse and/or any of your dependents are waiving coverage because you/they are currently covered for health care services with a Blue Cross and/or Blue Shield

Plan, an insurance company, an HMO, or other health care plan. Print the name of the person holding the contract, the name of the Blue Cross and/or Blue Shield Plan, the insurance company,

HMO or other health care plan, and the policy or Identification Number of the contract. If you and/or any of your dependents are waiving coverage and electing to have no health care coverage, write

"No Coverage" under the "Name of Health Care Plan/Insurance Co." column.

4. WAIVER INFORMATION

5. COVERAGE BEING WAIVED

Check the type(s) of coverage being waived for each

individual in section four.

Print the name, relationship, and Social Security Number of each eligible dependent waiving health care coverage under your group's contract.

This section may need to be completed with the assistance

of the Group Leader and should be reviewed by the Group

Leader.

6. STATEMENT AUTHORIZATION

Sign and date the Waiver of Group Health Insurance Coverage form (C-69).

This section should be completed by the