Waiver Of Coverage - Mercycare (Page 2 of 2) in pdf

Waiver Of Coverage - Mercycare Page 2

My dependent child (ren) is covered or will be covered under another plan that is not sponsored by my

employer. If currently covered, please attach your identification card for that plan. Please list the name (s)

of the child (ren) for whom coverage is being waived.

Other reason (Please provide a written reason for waiving coverage):

I certify that I have been given the opportunity to apply for group health insurance and decline to enroll as

indicated above, on behalf of myself, my spouse and my dependent child (ren). I understand that by signing this

waiver, I, my spouse, and my dependent child (ren) forfeit the right to coverage. I was not pressured, forced or

unfairly induced by my employer, the agent or the insurer (s) into waiving or declining the group health insurance.

If, in the future, I apply for coverage, I, my spouse, or any of my dependent child (ren) may be treated as a late

enrollee and subject to postponement or an exclusion of coverage for preexisting conditions for up to 18 months.

This period may be offset by the time I, my spouse or dependent child (ren) was covered under a qualified health

plan.

I understand that if I am declining enrollment for myself, my spouse, or my dependent child (ren) because of other

health insurance, I may in the future be able to enroll myself, my spouse, or my dependent child (ren) in this plan,

provided that I request enrollment within 30 days after my other health coverage ends. In addition, if I gain a

dependent spouse or child (ren) as a result of marriage, birth, adoption, or placement for adoption, I understand I

may be able to enroll myself, my spouse and my dependent child (ren), provided that I request enrollment 30 days

after the marriage, birth, adoption or placement for adoption.

Signature of Employee:

Date Signed :

Signature of Spouse :

Date Signed:

EMPLOYER MUST COMPLETE THIS SECTION

Company Name

Group # __________

Reason for Enrollment (Check One)

Open Enrollment (if applicable)

Date of Hire

New Hire

Qualifying Event

Effective Date

Authorized Signature (REQUIRED)_______________________________

mcwavjan2014

Waiver Of Coverage - Mercycare Page 2