Fillable CITY OF STEPHENVILLE WAIVER OF GROUP HEALTH INSURANCE (City of Stephenville)

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CITY OF STEPHENVILLE WAIVER OF GROUP HEALTH INSURANCE (City of Stephenville)

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CITY OF STEPHENVILLE
WAIVER OF GROUP HEALTH INSURANCE
NOTE: Attach copy of ID card for alternate plan to this form.
WAIVER OF COVERAGE
I do NOT elect the medical coverage offered by the City of Stephenville through the current enrollment period due to
the fact that I have employer sponsored group health insurance coverage through
. I understand that by waiving medical
coverage, I am not entitled to prescription coverage. I understand that by signing this waiver I am waiving coverage not
only for myself, but for my spouse and dependents, if applicable. I hereby decline the health insurance benefits
provided by the employee medical insurance plan through the City. The benefits of the plan have been explained to me
and I do not desire to participate in the plan.
I understand that this is a binding election until revoked during a future annual enrollment period or by the occurrence
of a qualified change in my family status as defined by the regulations issued by the Internal Revenue Service.
Notwithstanding the foregoing, however, I understand that if the alternate health insurance coverage I am currently
receiving should cease as a result of loss of eligibility or termination of employer contributions (or if it is COBRA coverage
which ceases because the coverage period has exhausted), I must notify the City of the termination of the alternate
health insurance coverage and request enrollment in the city medical plan within thirty-one (31) days of the termination
of coverage in order to become covered under the City’s plan. I understand that if I do not request enrollment within
thirty-one (31) days of termination of coverage, I will not be eligible to enroll for any City health coverage until the
following annual enrollment which shall be effective the first day of the following plan year.
Employee Signature Date
APPENDIX E
FORM 22
Date of Birth
Zip
State
City
Home Mailing Address:
Employee Number
Employee’s Names: (Last) (First) (Middle)
MYSELF & MYDEPENDENTS
or
I hereby certify that I have been given an opportunity to request health insurance under the group medical insurance
policy offered by the City of Stephenville, and after careful consideration, I have decided to waive coverage for:
Birth Date
/ /
/ /
/ /
/ /
Relationship
Dependents who are waiving:
Name of Dependent
Page 229 of 254
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CITY OF STEPHENVILLE WAIVER OF GROUP HEALTH INSURANCE (City of Stephenville)

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Completed 16 July 2020

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