Coverage Election Form

Name

First Name (Given Name)Middle InitialEMPLOYEE NAME Last Name (Family Name)
MF
Address (Street Number and Name)
Apt. Number
City or Town
Employee's Telephone Number
Format: (000) 000-0000.
ZIP Code
Date of Birth (mm/dd/yyyy)

MesDíaAño
Social Security Number
Date of Hire (mm/dd/yyyy)

MesDíaAño
Employee's E mail Address
Primary Care Physician
ENROLLWAIVE
I am being offered coverage throught my employer and I unsderstand that by electing, I may not alter, change, add or remove coverage unless there is a qualifying event. In such case I must notify my employer within 30 days of the qualifying event to make any changes.
Employee Signature

Limpiar
Date (mm/dd/yyyy)

MesDíaAño
MEDICAL Waiver of Coverage

I am refusing coverage at this time. I understand that will not be offered this insurance again until my open enrollment period.
Employee Signature

Limpiar
Date (mm/dd/yyyy)

MesDíaAño
IF YOU HAVE OBAMA CARE: I understand that i am waiving coverage. If I am currently covered with an individual plan with a subsidy from the govermment, I understand taht no longer qualify for the subsidy.
Should be Empty: