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
HA-0109-0519
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 _____ ______ ______
EMPLOYER CERTIFICATION
(See Instructions on reverse)
Employer
Name _________________________
Location #
(State Monthly)
10/12 - month employee
(Enter “10 or 12”)
MEMBER ACTION
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
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
