Health Insurance Rebate Form

HARRISON CENTRAL SCHOOL DISTRICT

Health Insurance Rebate Form
Eligible full-time employees who choose to decline health insurance coverage from the Harrison Central School District are eligible for a health insurance rebate, as specified by the applicable collective bargaining agreement. Complete and submit this form to apply for the health insurance rebate.
Are you a full-time employee?

YESNO
Since you are not a full-time employee, you are not eligible for this benefit.
Your Name*

First NameLast Name
Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Harrison Email Address*
doej@harrisoncsd.org
Your original date of hire HCSD:*

MonthDayYear
Date
Your Job Title:*
Choose the effective date to begin waiving health insurance.*

MonthDayYear
Date
I certify that I am currently enrolled in another health insurance plan with the following level of coverage:*

Single PersonTwo PersonFamily Coverage
Name of the person whose health insurance plan I am currently enrolled under as a dependent:*

First NameLast Name
The relationship of this person to me:*
How many dependents under the age of 26 are covered by this health insurance plan?*
Name of 1st person under age 26 on this health insurance plan:

First NameLast Name
Date of birth of 1st person under age 26 on this health insurance plan:

MonthDayYear
Date
Name of 2nd person under age 26 on this health insurance plan:

First NameLast Name
Date of birth of 2nd person under age 26 on this health insurance plan:

MonthDayYear
Date
Name of 3rd person under age 26 on this health insurance plan:

First NameLast Name
Date of birth of 3rd person under age 26 on this health insurance plan:

MonthDayYear
Date
Name of 4th person under age 26 on this health insurance plan:

First NameLast Name
Date of birth of 4th person under age 26 on this health insurance plan:

MonthDayYear
Date
Name of 5th person under age 26 on this health insurance plan:

First NameLast Name
Date of birth of 5th person under age 26 on this health insurance plan:

MonthDayYear
Date
Name of 6th person under age 26 on this health insurance plan:

First NameLast Name
Date of birth of 6th person under age 26 on this health insurance plan:

MonthDayYear
Date
Upload proof of enrollment in this health insurance policy (e.g., a copy/picture of your health insurance card, a declaration page from your health insurance policy listing you as a dependent):*

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HARRISON CENTRAL SCHOOL DISTRICT