Waiver of Group Health Benefits & Notice of Special Enrollment Rights

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 indecated 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, eligiblity for that other coverage (or if the employer stops contributing towards my or my eligible depentents' other coverage).

I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends ( or after the employer stops contributing towards the other coverage ). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment perios.

In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible depentent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I understand that in order to request special enrollment or obtain more information, I should contact my group administrator.