Health Care Coverage Waiver Form
On behalf of myself and my eligible dependents (if any), I waive the option to enroll in Ouachita
Parish Police Jury health insurance offered at this time for the following reason:
I am covered under another group plan as a spouse or dependent
I am covered by Medicaid, Medicare or TRICARE/Veteran’s Administration
I have coverage through an Individual plan, or purchased coverage through state or federal
Exchange
I am under another group plan sponsored by a second employer
I do not wish to participate in health care benefits at this time (I am declining health insurance
entirely)
Notice of Enrollment Rights
If you are declining enrollment for yourself or your dependents because of other health insurance
coverage, you may in the future be able to enroll yourself or your dependents in this health plan,
provided that you request enrollment within 30 days after your other coverage ends.
By signing below, I understand that I am waiving health insurance coverage offered by Ouachita
Parish Police Jury. I also understand that I may be able to enroll in health insurance with OPPJ at a
later date should my current health coverage end.
Print Name: _____________________________________________
Employee Signature: _______________________________________ Date: __________________
