MEDICAL PLAN WAIVER
Employees may elect to waive medical coverage on an annual basis and receive $750 annually in lieu of medical coverage by submitting this completed waiver form.
Declining Coverage:
I am declining medical plan coverage that is being offered by Pace University through the current enrollment period, and for all subsequent annual coverage periods, due to the fact that I have medical insurance coverage through______________________________________________________ .
Medical Insurance carrier
I understand that by waiving medical coverage, I am not entitled to prescription coverage. I understand that by signing this Waiver, I am waiving coverage, not only for myself, but for my Spouse/Domestic Partner and eligible dependent children, if applicable.
I understand that by signing this form I am attesting to alternate medical coverage.
Length of Waiver:
I understand that this is a binding election until revoked during a future annual enrollment period or by the occurrence of a qualified change in my family status as defined by Regulations issued by the Internal Revenue Service. Notwithstanding the foregoing, however, I understand that if the alternate health insurance coverage I am currently receiving should cease , I must notify Pace University of the termination of the alternate health insurance coverage and request enrollment in a Pace University Medical Plan within 31 days of the termination of coverage in order to become covered under Pace University’s Medical Plan(s). I understand that if I do not request enrollment within 31 days of termination of coverage, I will not be eligible to enroll for any University health insurance coverage until the following annual enrollment which shall be effective the first day of the following July 1st plan year.
I understand that the $750 cash option will be payable in equal semi-monthly payments (i.e.,$31.25/paycheck) effective 1st of the month for which I am eligible for medical coverage (e.g.,., July 1, 2007) until separation from Pace University or enrollment in a Pace University Medical Plan, whichever comes first.
Authorization:
EMPLOYEE SIGNATURE___________________________________________ DATE___________________
If you have any questions, contact the Benefits Office at (914) 773-3810
Revised May 3, 2007