Mclea Health Insurance Waiver Form printable pdf download

HEALTH INSURANCE WAIVER AUTHORIZATION FORM

Marion County Law Enforcement Association (MCLEA) Health Plans

PLEASE PRINT

Plan Year:

Employee’s Name

(LAST, FIRST, MI):

2016

Marion County Employee #:

Department:

Daytime Phone:

Sheriff’s Office

My signature below acknowledges that I elect to waive the medical/vision and dental

coverage under Marion County’s health plans, offered to me during:



New Employee Orientation (Hire Date: __ / __ /2016)



Open Enrollment



A Position/Status Change



Other

I am waiving the coverage offered to me by Marion County due to having coverage under

another health plan. I agree to provide proof of this coverage by submitting a letter

of confirmation from the insurance company through which I have the coverage or

from my spouse/domestic partner’s or parents’ employer. I understand that I must

contact Employee Benefits within 30-days if I lose this coverage.

I understand that by signing this form, I am making a binding election for my health

coverage for the 2016 plan year. I am aware that there is no financial incentive when

MCLEA employees waive coverage.

I further understand that I may not change my health care elections during the 2016 plan

year unless the changes are a result of—and consistent with—changes allowed under the

Internal Revenue Code and insurance carrier contracts, one of which is a loss of other

coverage.

I am aware that I may enroll myself, and if applicable, my eligible domestic partner,

spouse and/or children if coverage under the other plan is lost. I understand that in order

to do so, I must contact Employee Benefits to enroll within 30 days of the date my

coverage was lost. If I do not meet this requirement, I must wait until the next open

enrollment period. I understand that no exceptions will be made.

______________________________________

__________________

MCLEA Employee’s Signature (for waiving coverage)

Date Signed

______________________________________

__________________

Signature of Employee Benefits’ Staff Member

Date Signed

PLEASE RETURN COMPLETED FORM TO MARION COUNTY EMPLOYEE BENEFITS.

2012MCLEA WaiverFormHealthIns.doc

Mclea Health Insurance Waiver Form

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