Opt Out Program Election Form

OPT-OUT CAFETERIA PLAN ELECTION FORM 2015-2016
I wish to participate in the Opt-Out Cafeteria Plan (the “Plan”) and receive cash payments in lieu of
coverage. I elect to “Opt Out” of insurance coverage available through Irvington Board of Education (the
“Employer”), as noted, for the period July 1, 2015 through June 30, 2016.
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Single Medical
Single Prescription
Single Dental
Single Vision
$1,000.00
$500.00
$0
$0
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Family Medical
Family Prescription
Family Dental
Family Vision
$2,000.00
$1,000.00
$0
$0
Attach written proof of other coverage (letter from HR/Benefits Department or Certificate of
Coverage from Insurance Carrier with all dependents listed.
A copy of health insurance ID card will not be accepted.
In connection with my participation in the Plan, I fully understand and certify the following:
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The election to waive coverage under the Plan is entirely voluntary. The IBOE does not encourage any employee to receive
cash in lieu of adequate health and prescription insurance coverage.
I have qualifying, alternate health and/or prescription drug coverage and have provided written proof certifying the same.
I understand that payments made to me under the Plan are taxable income.
I understand that if I wish to enroll in the Employer’s plans at a later date, I will be subject to the Plan’s enrollment rules.
I understand that I must re-apply each year during the Open Enrollment to continue participation.
I understand that I must opt out of all plans (health, prescription, dental and vision) or the Employee Cost Share provisions of
Chapter 78 will apply.
Employee Name (please print)
School/ Department
Employee Signature
Date
Phone
For HR Use Only
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Acceptable proof of other coverage received
Past participant
New participant – confirm IBOE coverage terminated
Comments: ______________________________________________________________________________________________
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HR/Benefit Approval