Airport Quality Standards Program Covered Employee
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1AIRPORT QUALITY STANDARDS PROGRAM
COVERED EMPLOYEE VOLUNTARY WAIVER OF HEALTH BENEFITS FORM
This voluntary waiver form must be filled out by the employee, if s/he voluntarily chooses to do so.
You have been asked to complete this voluntary waiver form because your employer is requesting a
waiver from the program requirement per the QSP to provide health plan benefits to you. Your
employer may obtain a waiver from this legal requirement if you currently have health plan benefits.
Even if you have health plan benefits, your employer is required to provide health plan benefits to you,
unless you sign this form. If you want your employer to provide you with health plan benefits, do not
sign this form. It is illegal for your employer to force or to pressure you to sign this form.
You have the right to cancel or revoke this voluntary waiver at any time. Your revocation must be
submitted in writing. If you revoke this waiver, your employer will be required to provide health plan
benefits to you, if there is a Qualifying Change in your family status. If there is no Qualifying Change
you may not be able to enroll in coverage until at the Annual Enrollment.
You may request
information on Qualifying Change from your employer and/or employer health plan provider.
I hereby certify that I have health plan benefits as indicated below:
Employee Name:
Phone:
Address:
City: _____________________State:__________
Name of Employer:
Contact Person:
Phone:
If you have health plan coverage from another employer, employer of your parent, spouse, or domestic
partner and wish to provide a waiver to the employer listed above, please provide the information below:
Name of Employer Providing Health Coverage or Person Whose Coverage Extends to you:
His/her Relationship to You:
Employer Address:
Contact Person:
Phone:
Name of Health Insurance Provider:
Member ID: _____________
If you have health plan coverage through some other means, please explain:
I hereby waive the right to health plan benefits offered to me by the employer listed above.
Employee’s Signature
Date
March 30, 2010
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