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<br /> <br />HEALTH INSURANCE “OPT-OUT” PROGRAM <br />WAIVER APPLICATION <br /> <br /> I, _________________________, in consideration of the sum of $200 per month, <br />hereby waive my eligibility to obtain health insurance (medical only) from the City of <br />Mounds View for the period of January 1, ______ through December 31, _______. <br /> I hereby acknowledge that my decision not to participate in the City’s health plan <br />is made voluntarily, and that I have provided the City with proof of health insurance from <br />another provider. <br /> I further acknowledge that for the period of January 1, _____ to December <br />31,_____ I am only eligible to re-enroll in the City’s health insurance plan if one of the <br />below listed qualifying events occurs: <br />a. Marriage or divorce <br />b. Birth or adoption of a child <br />c. Death of a family member <br />d. Lack of other coverage through no fault of the employee or subscriber <br />e. Change in hours, which results in change of employment status <br />To re-enroll, I must notify the Assistant City Administrator within thirty (30) days <br />of one of the qualifying events listed above. <br /> <br /> <br />________________________ _______________________ <br />Print Name Signature <br /> <br />