Fillable 2019-2020 HEALTH INSURANCE DECLINATION FORM FOR FULL-TIME (FT) (ASA College)

Fill Online, Printable, Fillable, Blank 2019-2020 HEALTH INSURANCE DECLINATION FORM FOR FULL-TIME (FT) (ASA College) Form

Use Fill to complete blank online ASA COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

2019-2020 HEALTH INSURANCE DECLINATION FORM FOR FULL-TIME (FT) (ASA College)

On average this form takes 4 minutes to complete

The 2019-2020 HEALTH INSURANCE DECLINATION FORM FOR FULL-TIME (FT) (ASA College) form is 1 page long and contains:

  • 2 signatures
  • 3 check-boxes
  • 8 other fields

Country of origin: US
File type: PDF

U.S.A. forms for ASA College

BROWSE ASA COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
WWW.ASA.EDU
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
2019-2020 HEALTH INSURANCE DECLINATION FORM
FOR FULL-TIME (FT) EMPLOYEES
EMPLOYEE INFORMATION
ASA College Human Resources Oce
ASA College Health Insurance Coverage Plan
Name (Last, First): Employee #:
Department:
Title:
CIGNA - Trad. EPO - HIGH PLAN
CIGNA - H.S.A. - LOW PLAN
Medicare+ Gap Plans - age 65+
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I understand that this declination will remain in force until rescinded in writing and submitted to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.
_______________________________________
______________________
______________________
Received Date HR Assistant Name and Title
_______________________________________
HR Assistant Signature
_______________________________________
Employee’s Signature:
Date
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

2019-2020 HEALTH INSURANCE DECLINATION FORM FOR FULL-TIME (FT) (ASA College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document