Employee Benefits Declination Of Coverage (Sig Waiver Form) (Page 2 of 2) in pdf

Declining Coverage For:

Reason for Declining Health Coverage:

Myself

Medical

Dental

Vision

Covered by spouse’s group coverage.



Insurance Carrier:

Spouse

Medical

Dental

Vision

___________________________________

Children

Medical

Dental

Vision

Covered by parent’s group coverage.



Insurance Carrier:

I decline coverage in the indicated plans noted

___________________________________

above for the following dependents:

Covered by an individual Health plan.



Spouse Name:

_____________________________

Insurance Carrier:

___________________________________

Child Name: _____________________________

Covered by Medicare



Child Name: _____________________________

Medicare Eligibility Date:

___________________________________

Child Name: _____________________________

Other:



___________________________________

I acknowledge that the available coverages have been explained to me by my employer, and I know that I

have every right to apply for coverage. I have been given the chance to apply for this coverage and I have

decided not to enroll myself and/or my dependent(s), if any, and understand that evidence of insurability may

be required should I choose to apply for coverage at a later date. I have made this decision voluntarily and

understand that I will not be eligible to enroll until next open enrollment or experience a life event.

Effective January 1, 2014, I understand that the Healthcare Reform law requires all individuals to have

qualified medical plan coverage or pay a penalty for each month for failing to have coverage. Your employer

offers a medical plan that meets the minimum essential coverage and affordability rules, therefore this plan is

a qualified plan which makes any eligible employee ineligible for a government subsidy through Covered

California and it is my responsibility to report any changes to Covered California within 30 days. By declining

my employer’s coverage, I will be assuming responsibility in obtaining qualified medical coverage or be

subject to IRS penalties for not complying with the law.

If I acquire a new dependent as the result of marriage, birth, adoption or placement for adoption, I

acknowledge that I, and any dependents I may have, may request enrollment in my employer’s group benefit

plan(s) by applying for that coverage within 30 days of the marriage, birth, adoption or placement for

adoption.

If I have indicated above that the reason for declining coverage for myself or my dependent(s) is coverage

under another employer group benefit plan(s), I acknowledge that, if I or my dependent(s) involuntarily lose

coverage under the other employer group benefit plan(s), I must request enrollment for myself and/or my

dependent(s) in my employer group benefit plan(s) within 30 days. Otherwise, I understand I may not enroll

myself and/or my dependent in my employer’s group benefit plan(s) until the earlier or the end of my

employer’s next open enrollment period or 12 months and that “late entrant” provisions may apply.

_________________________________

_______________

________________________________

Employee Signature

Employee Name ‐ PRINT

Date

_________________________________

____________________

_______________

Name of District

Date of Hire

Effective Date

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Employee Benefits Declination Of Coverage (Sig Waiver Form) Page 2

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