Employee Waiver Form

Sex

Marital Status Date of Hire

I have other insurance through my spouse's employer.

Birth Date

Name (Last, First, MI)

Street Address

City, State & Zip

Social Security #

Phone #

Signature

Date

I have other insurance through my parent(s).

Other (please explain):

I have other insurance through the military.

I have my own insurance directly with an insurance carrier.

I have state or federal coverage through Medicare or Medicaid.

I have no health insurance and do not want any.

I have other insurance through my former employer (COBRA or Retirement).

Employee Waiver Form

This waiver form must be completed by any eligible employee who has voluntarily elected to waive his/her opportunity to

participate in the dealership's employer-sponsored group health plan.

I hereby certify that the medical benefits provided by my employer have been explained to me, and that I elect to decline to

participate in the plan. I understand by declining this offer I may not be offered another opportunity to participate unless I

marry, divorce, have a child (natural or adoption), have an involuntary loss of other health benefits, or any other involuntary

cause as defined under section 125 of the IRS code. I must request to enroll within 30 days after a qualifying event. I may

also enroll during the next open enrollment period. I also understand that my employer has offered me a compliant health

plan as defined by the Affordable Care Act (ACA). I understand that by electing not to enroll in this ACA compliant plan, I will

not be eligible for a premium subsidy at either a state based or federally operated insurance exchange.

Reason for decline (please choose one):