C12914 (4/21) Employee Application 9 of 9
Refusal of Coverage form
Complete this form if you, your spouse, domestic partner, or child dependent(s) are refusing this group health, dental, vision, and/or life insurance coverage offered through the
employer. (The employer must retain a copy of this form to provide to Blue Shield upon request.) Please type or print. Use black ink. *Note: The employee’s Social Security number
is required for all eligible employees.
Employee name Social Security number Date of birth
Employer (Group) name Hire date State of residence
Marital status Married Yes No
Domestic partnership Yes No
Job title
Is the employee a full-time employee, working at least 30 hours per week for this employer? Yes No Or
Is the employee a part-time employee, working at least 20 hours per week for this employer? Yes No
Declining coverage for:
I decline health plan coverage for:
Myself and all dependents.
My spouse/domestic partner only
My children only
My spouse/domestic partner and children only
The following dependents only:
________________________________________
If dental plan offered, I decline dental plan coverage for:
Myself and all dependents.
My spouse/domestic partner
My children
My spouse/domestic partner and children
The following dependents only:
________________________________________
If vision plan offered, I decline vision plan coverage for:
Myself and all dependents
My spouse/domestic partner
My children
My spouse/domestic partner and children
The following dependents only:
________________________________________
If life insurance plan offered, I decline life plan coverage for:
Myself
Reason employee is declining health coverage
OTHER EMPLOYER HEALTH COVERAGE
Enrolling as a dependent or an employee on this group health plan
Covered by this employer’s other health plan (through another carrier)
Covered by another employer’s health plan, including COBRA or Cal-COBRA coverage, through your spouse/domestic
partner, parent, or previous employer
OTHER NON-EMPLOYER HEALTH COVERAGE
Covered by an individual/family health plan
Covered by Government program, including Medicare, Medi-Cal, Healthy Families Program, TRICARE, Indian Health
Service, Tribal and Urban Indian Health Program, and Veterans Health Administration (VA)
OTHER REASONS
Reason employee is declining dental coverage
OTHER DENTAL COVERAGE
Enrolling as a dependent or an employee on this group dental plan
Covered by another employer’s dental plan, including COBRA or Cal-COBRA dental coverage, through your spouse/
domestic partner, parent, or previous employer
Covered by an individual/family dental plan
OTHER REASONS
Reason employee is declining vision coverage
OTHER VISION COVERAGE
Enrolling as a dependent or an employee on this group vision plan
Covered by another employer’s vision plan, including COBRA or Cal-COBRA vision coverage, through your spouse/
domestic partner, parent, o
r previous employer
Covered by an individual/family vision plan
OTHER REASONS
Reason employee is declining life insurance coverage
OTHER LIFE INSURANCE COVERAGE
Covered by another employer’s life insurance coverage through your spouse/domestic partner, or parent
OTHER REASONS
Cost of coverage
Do not need or do not want coverage
I acknowledge that the coverage available to me has been explained to me by my employer and I know that I have every right to enroll in this coverage and I have decided not to enroll
myself and/or my dependent(s), if any. I now decline to enroll myself, my spouse/domestic partner, and/or my child dependent(s) in my employer’s group health plan. I have made this
If I am declining enrollment for myself or my dependents because of other health coverage or because the employer stops contributing toward this coverage, I acknowledge that I may
be able to enroll myself and my dependents in this plan if I request enrollment within 60 days after my or my dependents’ other coverage ends or after the employer stops contributing
toward the other coverage.
In addition, if I acquire a new dependent as the result of marriage/domestic partnership, birth, adoption or placement for adoption, I acknowledge that I, and my dependents, may request
enrollment in my employer’s health plan by applying for that coverage within 60 days of the marriage/domestic partnership, birth, adoption, or placement for adoption. I also acknowledge
that if I, or my dependents, become eligible for the Healthy Families or the Medi-Cal Premium Assistance programs, I or my dependents may request enrollment in my employer’s health plan
by applying for coverage within 60 days of the notice of eligibility for these premium assistance programs.
within 60 days. Otherwise, I understand I may not enroll myself and/or my dependents in my employer’s health plan until the earlier of the end of my employer’s next open enrollment
period or 12 months.
Signature of employee Date
