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Waiver Form

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ABGH_UW102 SF.EEApp (6/2021) Page 1 of 5 Employee Enrollment Form EMPLOYER INFORMATION (must be completed) Company Name/DBA: Company Address: You must complete this form in its entirety in order for you or your dependents to be covered under the employer’s group health plan. If you are waiving coverage for yourself or your dependents, it must be clearly indicated on this form. If you do not complete this form in its entirety for yourself or your dependents at least 5 business days prior to the effective date, you or your dependents may not be eligible for coverage until the next open enrollment period. TO BE COMPLETED BY EMPLOYEE (if applying or waiving coverage) BENEFIT PLAN: GROUP NUMBER: A - EMPLOYEE (Primary Applicant) Legal Name: (Last) (First) (MI) Social Security Number: Gender: □ M□ FBirth Date (mm/dd/yyyy): Average number of hours worked per week? Date employed Full-Time: (mm/dd/yyyy) Home Street Address City State Zip Mailing Address (if different) Mailing Address City Mailing Address State Mailing Address Zip Home Phone: Work Phone Email Address: Cell Phone: Best Time to Call: Job Title: Status: □ Single ☐ MarriedEmployee Status: □ W2 ☐ 1099 ☐ Owner/PartnerCheck One: □ Full-Time ☐ Part-Time ☐ Retiree□ COBRA ☐ Cal-COBRACOBRA effective date(mm/dd/yyyy)Earnings Basis: □ Salaried□ Hourly□ CommissionNEW ENROLLMENT or WAIVER, please check one: □ New Hire ☐ Qualifying Life Event: Date: (mm/dd/yyyy) □ Re-hire ☐ COBRA□ Open Enrollment ☐ Waiver of Coverage (complete section B)□ New Group ☐ Other:B - WAIVER OF COVERAGE – DO NOT COMPLETE IF ENROLLING FOR COVERAGE Complete and sign if waiving any or all coverages for self. All eligible employees must be listed as either enrolling or waiving coverage when first eligible. Indicate the waiver reason below. □Individual Medical☐Medicare/Medicaid☐COBRA/Continuation ☐ Tricare☐Spouse’s/Parent Employer Plan□ Cost/Do not want (NO health coverage will exist) ☐ Other: _________________________________________________Neither I nor my dependents have been induced or pressured to decline coverage by my employer, the agent, or Allstate Benefits. My dependents and I have waived such coverage of our own accord. Signature: Date: Printed Name: Date employed Full-Time: Watchung Pediatrics76 Stirling Rd,Ste. 201 Watchung. NJ 07059