Rev. 2/19
PROOF OF OTHER COVERAGE STATEMENT
If you elect to WAIVE MEDICAL COVERAGE, to receive a cash allocation you must complete this
form, provide proof of other coverage* and sign the statement below.
Name:
Last First MI
I attest to having minimum essential coverage (as defined the Internal Revenue Service) through
another group health plan for myself, and coverage for all individuals that I reasonably expect
to claim as a personal exemption deduction for the taxable year and for the 2019 plan year to
be eligible to receive a cash payment. This proof of and attestation to coverage is required
every plan year.
Source of other coverage (i.e. employer name)
Insurance company or the organization providing coverage
*Acceptable proof of other coverage examples includes a current medical card or a confirmation of
enrollment letter from the medical plan or other employer
Please check the box below:
I certify that the above information is true and correct as of the date indicated below.
Signature
Date
Return the completed form to Human Resources as soon as possible. Thank you.
……………………………………………………………………………………………………………………………………………
HUMAN RESOURCES ONLY:
HIRE DATE: _________________
FULL-TIME PART-TIME _________
CASH ALLOCATION AMOUNT: ___________________
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