State Waiver for Health Insurance Form 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.).Employee First Name(Required) Middle Initial Employee Last Name(Required) Suffix (e.g., Sr., Jr.) 1. Did you accept your employer sponsored health insurance?(Required) Yes No None Offered 2. Did you agree to use your employer’s “Section 125 Cafeteria Plan” to purchase health insurance?(Required) Yes No None Offered 3. Do you have other health insurance?(Required) Yes No 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.SignatureDate Signed MM slash DD slash YYYY