Employee Coverage Waiver Form

Waiver of Coverage

I hereby acknowledge that I have been offered medical coverage through my employer and I am voluntarily choosing to WAIVE (DECLINE) enrollment in the employer-sponsored medical plan.

I understand that by waiving coverage at this time, I may not be eligible to enroll until the next Open Enrollment Period or unless I experience a qualifying Special Enrollment Event.

Important Notice

By opting out of employer-sponsored medical coverage, you acknowledge and understand that

you will generally not be eligible for a premium tax credit for coverage purchased through

the Affordable Care Act (ACA) Marketplace, if the employer coverage offered is considered

affordable and meets minimum value standards.