Waiver Acknowledgement Form CITY OF BROCKTON Department of Human Resources Step 1 of 2 50% CAPTCHAWaiver of Group Insurance / Effective Date AcknowledgmentDentalEmployee's Name: Date of Birth: Title: Please Check One: I waive my employer’s group dental insurance for myself and my dependents (if any) I am enrolling my employer’s group dental insurance coverage, but I am waiving coverage for my dependents Even though I have added my dependent/spouse to my health insurance, I do not wish to add them to my dental insurance at this time Even though I have added my dependents to my dental insurance, At this time I do not wish to add Dependent not added: Reasons for waiving coverage – please check one: Covered through spouse’s employer. Covered through another source. Other reason (explain) Employer Name: Insurance Company Name: Insurance Company Name: Please explain reason: As a result, I waive my and/or my dependents (if any) eligibility to enroll in my employer’s group plan at this time. I understand that although I declined enrollment for myself or my dependents (including spouse) because of other dental insurance coverage, I as the employee, may in the future, request enrollment within 30 days after the coverage ends due to an involuntary cancellation, or at the time of my employer’s annual open enrollment. In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30-days after the event. **** DATE ACKNOWLEDGMENTDate Acknowledgment I realize that I do not have any dental insurance though the City of Brockton until this date. My chosen effective date for coverage is: Employee's Signature:Date: MM slash DD slash YYYY Waiver of Group Insurance / Effective Date AcknowledgmentHealthPlease Check One: I waive my employer’s group health insurance for myself and my dependents (if any) I am enrolling my employer’s group health insurance coverage, but I am waiving coverage for my dependents Even though I have added my dependent/spouse to my dental insurance, I do not wish to add them to my health insurance at this time Even though I have added my dependents to my health insurance, At this time I do not wish to add Dependent not added: Reasons for waiving health coverage – please check one: Covered through spouse’s employer. Covered through another source. Other reason (explain) Employer Name: Insurance Company Name: Insurance Company Name: Please Explain Reason: As a result, I waive my and/or my dependents (if any) eligibility to enroll in my employer’s group plan at this time. I understand that although I declined enrollment for myself or my dependents (including spouse) because of other health insurance coverage, I as the employee, may in the future, request enrollment within 30 days after the coverage ends due to an involuntary cancellation, or at the time of my employer’s annual open enrollment. In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30-days after the event. **** DATE ACKNOWLEDGMENTDate Acknowledgment I realize that I do not have any health insurance though the City of Brockton until this date. My chosen effective date for coverage is: Employee's Signature:Date: MM slash DD slash YYYY
