PART 2: To be completed by the employer. Check one box below.
We will pay the above employee $___________________ every ____________________ in place of providing SHBP or
SEHBP coverage. We understand that this payment may not be more than 25 percent of the amount saved by the employer
because of the waiver or $5,000, whichever is less.
We request reinstatement of this employee’s SHBP or SEHBP coverage.
The reinstatement application must be ﬁ led within 60 days of the loss of other health coverage. If this timetable is followed,
the coverage will be retroactive to the date of loss. If the 60 day time limit has passed, the employee must wait until the next
open enrollment period to reenroll.
MAIL COMPLETED APPLICATION TO: New Jersey Division of Pensions & Beneﬁ ts
Health Beneﬁ ts Bureau
P.O. Box 299
Trenton, NJ 08625-0299
State Health Beneﬁ ts Program (SHBP) • School Employees’ Health Beneﬁ ts Program (SEHBP)
ACTIVE LOCAL GOVERNMENT AND LOCAL EDUCATION EMPLOYEE GROUP
EMPLOYEE COVERAGE WAIVER/REINSTATEMENT FORM
PART 1: EMPLOYEE INFORMATION — Last Name First MI
Gender Birth Date Social Security Number Marital Status*
Telephone Number Personal Email Address
Home Address No. and Street Name
City State Zip
EMPLOYMENT STATUS Full Time National Guard
Effective Dates Event Reason:
H _____ ______ ______
Rx _____ ______ ______
(See Instructions on reverse)
10/12 - month employee
(Enter “10 or 12”)
New Enrollment Existing
Date Employment Began
Signature of Certifying Ofﬁ cer
Telephone # Date Mailed
Check one box below.
Waiver of Coverage
In accordance with P.L. 2007, c. 92 (Chapter 92) and P.L. 2010, c. 2 (Chapter 2), I have agreed
to waive coverage (medical and, if applicable, prescription drug coverage) with the State
Health Beneﬁ ts Program (SHBP) or School Employees’ Health Beneﬁ ts Program (SEHBP)
to which I am entitled because I am covered under other health coverage. I understand that I
am not eligible for the waiver incentive if my other coverage is with the SHBP or SEHBP. Note:
You must submit proof of the other health coverage to your employer along with this form.
In place of health beneﬁ t coverage, my employer will pay me the amount shown in Part 2 below. I understand that I may
resume SHBP or SEHBP coverage when I am no longer covered by the other health coverage, provided that I notify
the Health Beneﬁ ts Bureau within 60 days of the loss of the other coverage and provide proof of loss of that coverage.
I wish to waive (check one) Medical Coverage Prescription Coverage Both
Reinstatement of Coverage
I previously waived SHBP or SEHBP coverage because I had other health coverage. As of _____/_____/_____, I
am no longer covered by the other health plan, request reinstatement of health beneﬁ ts coverage with the SHBP or
SEHBP, and have provided proof of loss of the other coverage. I further understand that coverage is permitted as an
employee, retiree, or dependent; however, multiple coverage under the SHBP or SEHBP is prohibited. A Health Ben-
eﬁ ts Enrollment and/or Change Form, along with proof of loss of other coverage, is required for all reinstatements.
Employee’s Signature ________________________________________________________ Date _____/_____/____
DIVISION USE ONLY
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