INSURANCE WAIVER
Select Location Name:
Print Name: Today’s Date: _
Date [MM/DD/YYYY]
Social Security Number: Hire Date:
Date [MM/DD/YYYY]
Having met the eligibility requirements, you are being offered the opportunity to enroll in medical,
dental and vision coverage plan. You have the right to decline or waive coverage. If you do waive
coverage for yourself, you may not cover dependents under the Employer’s medical, dental and vision
plan through the Plan year.
Note that if you waive coverage considered affordable and minimum essential under the Patient
Protection and Affordable Care Act (ACA), you may not qualify for government credits and subsidies to
purchase individual health insurance on the Marketplace.
• If you waive coverage, you cannot enroll in Alden’s medical, dental and vision plan until the
next open enrollment, unless you experience a qualified change in status. Examples include if
you are covered under another plan but that coverage is lost, or to add a new dependent
through birth, adoption, or marriage. However, you must request to enroll in your plan within 30
days of the qualified change in status. If you miss the 30-day enrollment deadline, you must
wait until open enrollment. For further details please review Summary Plan Description
Document.
I acknowledge that the Employer has offered me affordable minimum essential coverage,
as defined under the ACA, for the Plan Year that ends on December 31, 2022.
Medical Waiver Dental Waiver
Vision Waiver
Health & Dental Waiver Reason – [ check reason]
I have read the above and I understand the consequences of my waiver of coverage.
Signature of Employee Date [MM/DD/YYYY]
Insurance Waiver P a g e | 1 of 1
Alden, Inc.
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