AAA Election Waiver

AAA Election Waiver
Name

First NameLast Name
Date of Hire

MonthDayYear
Date
Effective Date:

MonthDayYear
Date
Qualifying Event
Plan for Period 12/01/2024 to 11/30/2025

I acknowledge that I have been offered the opportunity to purchase affordable, minimal value medical insurance for myself and my dependents through AAA Northway.

Ielect to participate in the following benefit plans through AAA Northway; which allows for my contributions towards the cost of these plans to be made on a pre-tax basis. | understand that I cannot change or revoke my election(s) at any time during the plan year unless I have a change in family status, or other change of life event.

I further understand that if I waive any of the coverage(s) for myself and/or eligible dependents at this time, the next opportunity to enroll will be during Open Enrollment in December 2025 or upon a qualified life event as long as my employer is notified within 30 days of the change.
Medical – High Deductible - Anthem
Medical – Co-Pay - Anthem
If medical is elected you will also be enrolled in AllyHealth Telemedicine
Email
example@example.com
Medical insurance
I have Insurance through
Dental – Anthem
Dental insurance
I have dental insurance through
Vision – Anthem
Vision insurance
I have vision insurance through
Signature
Date

MonthDayYear
Date
Should be Empty: