CHEIBA Trust

Waiver of Insurance
A. EMPLOYEE INFORMATION
Employee Last Name Employee First Name MI
Social Security Number

-
-

Medical Group Number
Name of Institution


B. WHO IS WAIVING INSURANCE: (Check all that apply)
EMPLOYEE
SPOUSE
DOMESTIC PARTNER
CIVIL UNION PARTNER
CHILD(REN)


C. I/WE DO NOT WISH TO PARTICIPATE IN THE GROUP INSURANCE PLAN, AT THIS TIME, FOR THE FOLLOWING REASON(S):
I have other group health insurance
I choose to have no coverage do to my religious affiliation
I have other coverage through the U.S. Military Services



D. LIST ALL DEPENDENTS NOT PARTICIPATING IN GROUP COVERAGE INCLUDING SPOUSE
DEPENDENT NAME
BIRTHDATE
RELATIONSHIP
(First, Middle Initial, Last)
(MM/DD/YYYY)



















I hereby certify that I have been given the opportunity to participate in my Employer’s Group Insurance Plan. The
plan has been explained to me and I decline to participate.

If I am declining enrollment for myself and/or my dependents (including my spouse, Domestic Partner, and Civil
Union Partner) because of other group or individual health insurance coverage, I may in the future be able to enroll
myself and/or my dependents in this plan, provided that I request enrollment within 31 days after a qualifying
event. In addition, if I have a new dependent as a result of marriage, birth, adoption or placement for adoption, I
may be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the
marriage, birth, adoption or placement for adoption.


It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages.

EMPLOYEE
DATE
SIGNATURE
COLORADO HIGHER EDUCATION INSURANCE BENEFIT ALLIANCE WAIVER OF INSURANCE


WHITE / Anthem – CANARY / Group Administrator – PINK / Member
S:\#cus-m-z\State Colleges (CHEIBA)\Client Documents\Open Enrollment Materials\2014 CHEIBA Waiver of Insurance.doc
FORM NO. 80084-CHEIBA Rev. 05/14