Employee Benefits Declination Of Coverage (Sig Waiver Form) printable pdf download

Employee Benefits Declination Of Coverage (Sig Waiver Form)

EMPLOYEE BENEFITS ‐ DECLINATION OF COVERAGE

SIG Waiver Form

Please read and complete this form if any coverage is declined or refused by an eligible employee

and their eligible family members:

Employee Benefits Eligibility with Schools Insurance Group:

All regular full‐time employees working 20 or more hours per week. Check with your school district

for effective date.

Eligible Dependents include:

∙ Your legal spouse

∙ Your qualified domestic partner

∙ Your children until age 26

∙ Your qualified domestic partner’s children until age 26

∙ Your dependent child who is incapable of self‐support because of a mental or physical disability

Your benefit elections or declination of coverage remains in effective until Schools Insurance

Group’s next Open Enrollment unless you have a qualifying life event as defined by the IRS:

 The addition of a dependent through birth, adoption or marriage

 The loss of a dependent through divorce or death, or if your child reaches the maximum age

limit for coverage

 A change in your or your spouse’s employment status from full‐time to part‐time or vice

versa

 A substantial change in your benefits coverage or a spouse’s coverage

 The addition or separation of a qualified domestic partner

 Change in eligibility for Medicaid or Children’s Health Insurance Program (CHIP) subsidy

If you experience a family status change and want to change your benefits, you MUST contact

Human Resources within 30 days of the change.

If you decline enrollment for yourself or your dependent (including your spouse) because of other

health insurance coverage and that coverage ends, you may be able to enroll yourself or your

dependents in this plan outside of Open Enrollment. In order to exercise this option, you must

request enrollment during the first 30 days after your other coverage ends.

Employee: Last Name__________________ First Name_________________

Full Time

Part Time

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Employee Benefits Declination Of Coverage (Sig Waiver Form)