Download Waiver of Employee Health Insurance Form (Messiah)

WAIVER OF HEALTH INSURANCE
In consideration of Messiah College’s promise to pay a waiver bonus in the amount of
$1,000.00 (paid on a pro-rated basis), I agree to waive the health insurance coverage
provided by the College. I understand that my waiving of coverage is in effect for the
entire plan year beginning July 1, 2016 and ending on June 30, 2017 unless I
experience a qualified family status change.* The waiver is not available for
employees who have a benefits-eligible spouse working at Messiah College. I hereby
state that I will be covered by another health insurance plan during the entire period of
the waiver as indicated below:
Other Health Insurance Information
Name of Policy Holder
Policy Holder’s Employer
Name of Health Care Plan/Insurance
Employee Signature
Date
Please print name
* Family status changes are governed by the Internal Revenue Code and include
marriage, divorce, birth or adoption of a child, death of spouse or child, spouse
beginning or terminating employment and you or a spouse having a significant
change in work hours that affects your benefits coverage.