Opt Out Health Insurance Form
Name: _______________________________________________________
Date: ________________________________________________________
Address: _____________________________________________________
Spouse: ______________________________________________________
Dependents Name and ages: _____________________________________________
Current Coverage: Single ________; Mem. + One ________; Family ________
I ___________________________________ am voluntarily opting out of the City of
Meriden’s Health Insurance Plan. In exchange I will no longer have to pay the weekly
cost share and will receive an incentive (if I qualify) of $500 for single coverage; $1000
for member + one; or $1500 for family coverage. These payments will be made in July of
I have attached proof of other non City of Meriden/Board of Education coverage.
I understand that I may opt back in for July 1
of the following year unless other
coverage is terminated due to federally documented death, divorce, or loss of
employment. If employees opt back in due to one of the above qualifying events, they
must make arrangements with the Personnel Department to pay back a prorated portion
of the opt out provision (i.e., $125 per month of opt back for family) prior to being put
back on to the City’s health insurance. Employees may only return on the first of each
month and must have requested to return any paid monies owed at least fifteen (15)
calendar days prior to the first of the month.
For this year I may opt out until June 1, 2018.
_______________________________________ ________________________
Signature Date
_______________________________________ _________________________
Human Resources Director Date
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