Yorktown Central School District

DECLINATION OF HEALTH INSURANCE Name

Date

Job Title

Building

I acknowledge that I have been offered the opportunity to purchase health coverage for myself and my dependents, through my employer, Yorktown Central School District. I decline to participate in Yorktown Central School District Health Plan for the following reason (check one): Another plan offered by my employer or former employer I am covered by group coverage plan offered by my spouse or parent An alternative individual plan A government plan (type) COBRA or State Continuation I and/or my dependents are currently not covered by any other health benefit plan Other (explain):

To receive the declination pay-out offered by the YCSD, you MUST submit a copy of your current health insurance card along with this form. If you decline coverage and are not covered under another plan   

Under the Affordable Care Act, if you refuse employer coverage and do not obtain coverage on your own, you will be subject to a penalty. If you are not covered under another plan, you cannot enroll in Yorktown Central School District plan until the next open enrollment. If you waive coverage without being covered under another plan, you may be subject to a pre-existing condition limitation when you eventually enroll in the plan. Signature of Employee:

For office use only:

Declination Start Date: ______________________