Eastern Michigan University
Health Care Plan Waiver of Coverage Form
Employee Name (Last, First, MI)
By my signature below, I hereby waive, for myself and each of my dependents, all eligibility for and/or
participation in Eastern Michigan University's group medical insurance plans effective January 1, 2017, or
my 2017 benefits-eligibility date, if later than January 1, 2017.
I understand and acknowledge that:
A. I am eligible for and have been
offered the opportunity to participate in an EMU-sponsored health
care plan.
B.
This waiver will remain in effect until elect medical insurance coverage under a Health Care plan
during a
future Eastern Michigan University Open Enrollment period (provided I am employed in a
benefits-eligible category at the time), or I enroll in an Eastern Michigan University Health Care plan
within 30 days of
experiencing a qualified change in status as defined by IRS rules and regulations.
C.
If I am in the Clerical/Secretarial (CS), Food Service/Maintenance (FM), Campus Police (CP) Faculty
(FA), or Lecturer (LE) employment classification, I may be entitled to a Health Care Waiver Payment
("Waiver Payment")
*
if I am participating in another medical insurance plan (other than EMU's)
during the entire period when this waiver is in effect. I am currently participating in the following
medical insurance plan.
D.
Name of Employer Providing Health Plan Coverage:
Employer City, State, ZIP:
Waiver Payments are subject to the terms and conditions set forth in the Agreements between Eastern
Michigan
University and its various non-bargained-for and bargaining units as they may be revised or
amended from time-to-time.
*Waiver Payments (paid annually divided evenly over each pay)
FM, LE Employees- $1,200/ FA, CP Employees- $2,000/ CS Employees- Max allowed by law, not to exceed $2,000
