W A I V E R
HEALTH and/or DENTAL COVERAGE
This form is to be completed by all City of Milwaukee employees who do not elect
the City of Milwaukee health insurance benefits.
I, , the undersigned, understand that I am eligible for a
(print last name, first name)
qualified health plan, according to the Affordable Care Act, through the City of Milwaukee. I
understand I am eligible for dental benefits. By execution of this waiver form, I hereby waive my
rights to health and/or dental coverage by checking the appropriate box below, signing and dating
this form. I understand that if I should want such coverage in the future, I may be required to wait
until the next open enrollment period to enroll (if there is not a qualifying event).
I further understand that if I do not have other health insurance benefits or coverage through a
spouse or family member, I will be subject to the Affordable Care Act, and any financial penalties
associated with not having health insurance benefits.
I understand that this waiver does not affect my eligibility for health or dental insurance
benefits as a result of my obtaining coverage as the dependent of another City employee under a
City of Milwaukee health or dental plan.
If you have any questions about this form, contact Employee Benefits Division (EBD) at 286-3184.
Please check 1 of 3
___ I elect to waive only my health coverage.
___ I elect to waive only my dental coverage.
___ I elect to waive both my health and dental coverage.
REASON FOR HEALTH WAIVER (please check 1 of 3)
1 Married to other City employee
Spouse or Parent Name:
2 Refused Coverage
3 Other Coverage
Emplid:
EMPLID (6 digit): Dept/Div:
CANCEL EFFECTIVE DATE (1
st
of Month only)
EMPLOYEE SIGNATURE: DATE SIGNED:
NOTE: Return this form to Employee Benefits Division, Room 701, City Hall Updated 9.12.16
