State Waiver for Health Insurance Form

Brockton City Seal (grayed)

CITY OF BROCKTON

Department of Human Resources

 

 

Employee Health Insurance Responsibility Disclosure Form

You are completing this form because you have declined to participate in your employer sponsored health insurance plan and/or have declined to participate in the employer’s “Section 125 Cafeteria Plan” pre-tax purchasing arrangement. A Section 125 Plan is not health insurance; it is a way to purchase health insurance on a pre-tax basis. For information about affordable health insurance options, visit the Commonwealth Connector at www.mahealthconnector.org .

EMPLOYEE INFORMATION

Employee First Name
The employee or employer must enter the employee’s first name.

Employee Last Name
The employee or employer must enter the employee’s last name.

Question 1
The employee must indicate Yes, No, or None Offered if health insurance is not offered (check box).

Question 2
The employee must indicate Yes, No, or None Offered if a “Section 125 Cafeteria Plan” is not offered (check box).

Question 3
The employee must indicate Yes or No (check box).

Employee Signature
The employee must sign and date the Employee Health Insurance Responsibility Disclosure (HIRD) form.

Note to Employer Regarding Employee Signature
If the employee refuses to sign and date the form, the refusal should be noted in writing and signed by the authorized company representative (e.g., the owner, supervisor or manager, chief executive officer, etc.).

1. Did you accept your employer sponsored health insurance?(Required)
2. Did you agree to use your employer’s “Section 125 Cafeteria Plan” to purchase health insurance?(Required)
3. Do you have other health insurance?(Required)

Employee Affidavit

I hereby affirm, under penalties of perjury, that all the information provided herein is true to the best of my knowledge. I also understand that if I do not have health insurance I may be responsible for the full costs of all medical treatment, that I may forfeit all or a portion of my Massachusetts personal tax exemption and be subject to other penalties pursuant to M.G.L c. 111M, that the Employee Health Insurance Responsibility Disclosure (HIRD) Form contains information that must be reported in my Massachusetts tax return, and that I am required to maintain a copy of the signed HIRD Form.
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