WWW.ASA.EDU
2019-2020 HEALTH INSURANCE DECLINATION FORM
FOR FULL TIME EQUIVALENT (FTE) EMPLOYEES
(for employees working 30-39 hours per week)
EMPLOYEE INFORMATION
ASA College Health Insurance Coverage Plan
Name: Employee #:
Department:
Title:
CIGNA - MVP H.S.A.
I __________________________________________________________________________ certify
that I am declining insurance coverage through the ASA Health Insurance Coverage Plan.
I understand that this declination also eliminates dependent eligibility through this plan.
If I choose to accept this policy in the future, coverage will not be available until the next open
enrollment, following that decision.
I understand that this declination will remain in force until rescinded in writing and submitted to
the ASA College Human Resources Oce.
DOWNTOWN BROOKLYN
151 Lawrence Street
Brooklyn, NY 11201
Tel: 718 - 522-9073
HIALEAH
530 West 49th Street
Hialeah, FL 33012
Tel: 786-279-2643
MIDTOWN MANHATTAN
1293 Broadway/One Herald Center
New York, NY 10001
Tel: 212-672-6450
ASA College Human Resources Oce
_______________________________________
______________________
______________________
Received Date HR Assistant Name and Title
_______________________________________
HR Assistant Signature
_______________________________________
Employee’s Signature:
Date
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