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    << November 2020 >>
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  • 2021 - Waiver of Medical Coverage, Acceptance of Ancillary Benefits
    FULL TIME EMPLOYEES ONLY
    FOR USE FOR 2021 ENROLLMENT ONLY
     
    To Be Completed By Employee:
    Employee Name:
    Social Security Number:
    Date of Birth:
    1. I hereby certify that I have been advised of the employee benefit coverage’s provided by the Trust and of the employee co-payments required for such coverage’s.
    2. By executing this Waiver, I hereby elect not to participate in the benefit programs provided by the Trust for medical, prescription drug and hospital care because I have access to other group health coverage.
    3. I make this Waiver voluntarily and understand that by executing it I am waiving all coverage by the Trust for myself, my spouse, and our dependents, if any, for the benefits described in paragraph 2.
    4. I further understand that this Waiver will be effective for the duration of the current plan year and may not be revoked until the next designated open enrollment period unless I lose access to my other group health coverage.
    5. I (we) understand that the form for Waiver of Medical Coverage must be returned to the Fund Office by December 4, 2020, to waive medical coverage effective January 1, 2021. 
    6. I understand that I will remain eligible for the chiropractic, hearing, dental, vision, legal services, life insurance and short term disability benefits provided by the Trust and for purposes of those benefits, I hereby state that my spouse, dependents or designated beneficiary(ies) are as follows:
    Spouse Name:
    Social Security Number:
    Date of Birth:
    Dependent Name:
    Social Security Number:
    Date of Birth:
    Dependent Name:
    Social Security Number:
    Date of Birth:
    Life Insurance Beneficiary:
    Social Security Number:
    Date of Birth:

    I am waiving coverage for the year of 2021.  I understand that I have been offered the opportunity to enroll myself and my dependents in my employer-sponsored medical coverage through this group plan that is both affordable and valuable in accordance with the Affordable Care Act (Health Reform).   I understand that without a qualifying event pursuant to HIPAA special enrollment rights, I will not be permitted to enroll in this Plan again until the Plan’s next annual enrollment period.  I also understand that without medical coverage I (and my dependents, if any) could have a financial penalty applied when my/our personal income taxes are filed with the IRS.

    Signature (type full name):
    Employee Number:
    Date:
    Address:
    Apt. No:
    City, State: ,
    Zip Code:
    Spouse Signature (type full name):
    Date:


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