C12 914 (7/21) 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 c Yes c No
Domestic partnership c Yes c No
Job title
Is the employee a full-time employee, working at least 30 hours per week for this employer? c Yes c No Or
Is the employee a part-time employee, working at least 20 hours per week for this employer? c Yes c No
Declining coverage for:
I decline health plan coverage for:
c Myself and all dependents.
c My spouse/domestic partner only
c My children only
c My spouse/domestic partner and children only
c
The following dependents only:
________________________________________
If dental plan offered, I decline dental plan coverage for:
c Myself and all dependents.
c My spouse/domestic partner
c My children
c My spouse/domestic partner and children
c The following dependents only:
________________________________________
If vision plan offered, I decline vision plan coverage for:
c Myself and all dependents
c My spouse/domestic partner
c My children
c My spouse/domestic partner and children
c The following dependents only:
________________________________________
If life insurance plan offered, I decline life plan coverage for:
c Myself
Reason employee is declining health coverage
OTHER EMPLOYER HEALTH COVERAGE
c Enrolling as a dependent or an employee on this group health plan
c Covered by this employer’s other health plan (through another carrier)
c 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
c
Covered by an individual/family health plan
c 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)
c OTHER REASONS
Reason employee is declining dental coverage
OTHER DENTAL COVERAGE
c Enrolling as a dependent or an employee on this group dental plan
c
Covered by another employer’s dental plan, including COBRA or Cal-COBRA dental coverage, through your spouse/
domestic partner, parent, or previous employer
c Covered by an individual/family dental plan
c OTHER REASONS
Reason employee is declining vision coverage
OTHER VISION COVERAGE
c Enrolling as a dependent or an employee on this group vision plan
c
Covered by another employer’s vision plan, including COBRA or Cal-COBRA vision coverage, through your spouse/
domestic partner, parent, or previous employer
c Covered by an individual/family vision plan
c OTHER REASONS
Reason employee is declining life insurance coverage
OTHER LIFE INSURANCE COVERAGE
c
Covered by another employer’s life insurance coverage through your spouse/domestic partner, or parent
OTHER REASONS
c Cost of coverage
c 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
decision voluntarily, and no one has tried to inuence me or put any pressure on me to decline coverage.
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.
If I have indicated above that the reason for declining coverage for myself or my dependent(s) is coverage under another employer health benet plan, I acknowledge that if I or my
dependent(s) involuntarily lose coverage under the other employer health benet plan, I must request enrollment for myself and/or my dependent(s) in my employer health benet plan
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
