Waiver of Group Health Benefits & Notice of Special Enrollment Rights

Employer: _____________________________________________
Please complete the following:
For the plan year effective ___ / ___ / ______ I am waiving coverage for:
I am waiving coverage due to:
Special Enrollment Notice and Certification – Please review and sign below if you wish to waive coverage. By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. I am declining enrollment as indicated above. I understand that I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose, or my eligible dependents lose, eligibility for that other coverage (or if the employer stops contributing towards my or my eligible dependents’ other coverage). I understand that in order to request special enrollment or obtain more information, I should contact my group administrator.
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