Refusal of Coverage form

Complete this form if you, your spouse, domestic partner, or child dependent(s) are refusing this group health, dental, vision, and/or life insurance coverage offered through the
employer. (The employer must retain a copy of this form to provide to Blue Shield upon request.) Please type or print. Use black ink. *Note: The employees Social Security number
is required for all eligible employees and dependents.
Employee name Social Security number Date of birth

Employer (Group) name Hire date State of residence

Marital status Married Yes No Job title

Domestic partnership Yes No
Is the employee a full-time employee, working at least 30 hours per week for this employer? Yes No
Is the employee a part-time employee working at least 20 hours per week for this employer? Yes No
Declining coverage for: Reason for declining coverage
I decline health plan coverage for:
OTHER EMPLOYER HEALTH COVERAGE
Myself and all dependents.
Enrolling as a dependent on this group health plan
My spouse/domestic partner only
Covered by this employers other health plan (through another carrier)
My children only
Covered by another employers health plan (e.g., through your spouse/domestic partner)
My spouse/domestic partner and children only
Carrier name ________________________________
The following dependents only:
ID number __________________________________
_________________________________________________________ Covered by TRICARE
If dental plan offered, I decline dental plan coverage for: OTHER NON-EMPLOYER HEALTH COVERAGE
Myself and all dependents. Covered by an individual health plan.
My spouse/domestic partner Carrier name ________________________________
My children ID number __________________________________
My spouse/domestic partner and children Covered California or other State Health Exchange
The following dependents only: Medicare, Medi-Cal, Healthy Families Program
_________________________________________________________ Other ______________________________________

C19927 (1/15)
If vision plan offered, I decline vision plan coverage for: OTHER DENTAL COVERAGE
Myself and all dependents Enrolling as a dependent on this group dental plan
My spouse/domestic partner Covered by another employers dental plan (e.g., through your spouse/domestic partner)
My children Carrier name ________________________________
My spouse/domestic partner and children ID number __________________________________

Blue Shield of California, an independent member of the Blue Shield Association

The following dependents only: Other ______________________________________
_________________________________________________________
OTHER VISION COVERAGE
If life insurance plan offered, I decline life plan coverage for: Enrolling as a dependent on this group vision plan
Myself and all dependents
My spouse/domestic partner and children Covered by another employers vision plan (e.g., through your spouse/domestic partner)
Carrier name ________________________________
ID number __________________________________
Other ______________________________________

OTHER LIFE INSURANCE COVERAGE

Covered by another employers life insurance coverage (e.g., through your spouse/
domestic partner)
Carrier name ________________________________
ID number __________________________________
Other ______________________________________
I acknowledge that the coverage available to me has been explained to me by my employer and I know that I have every right to enroll in this coverage and I have decided not to enroll
myself and/or my dependent(s), if any. I now decline to enroll myself, my spouse/domestic partner, and/or my child dependent(s) in my employers group health plan. I have made this
decision voluntarily, and no one has tried to influence me or put any pressure on me to decline coverage.
If I am declining enrollment for myself or my dependents because of other health coverage or because the employer stops contributing toward this coverage, I acknowledge that I may
be able to enroll myself and my dependents in this plan if I request enrollment within 31 days (60 days if loss of Medi-Cal or Healthy Families coverage) after my or my dependents
other coverage ends or after the employer stops contributing toward the other coverage.
In addition, if I acquire a new dependent as the result of marriage/domestic partnership, birth, adoption or placement for adoption, I acknowledge that I, and my dependents, may request
enrollment in my employers health plan by applying for that coverage within 31 days of the marriage/domestic partnership, birth, adoption, or placement for adoption. I also acknowledge
that if I, or my dependents, become eligible for the Healthy Families or the Medi-Cal Premium Assistance programs, I or my dependents may request enrollment in my employers health plan
by applying for coverage within 60 days of the notice of eligibility for these premium assistance programs.
If I have indicated above that the reason for declining coverage for myself or my dependent(s) is coverage under another employer health benefit plan, I acknowledge that if I or my
dependent(s) involuntarily lose coverage under the other employer health benefit plan, I must request enrollment for myself and/or my dependent(s) in my employer health benefit plan
within 31 days. Otherwise, I understand I may not enroll myself and/or my dependents in my employers health plan until the earlier of the end of my employers next open enrollment
period or 12 months.

Signature of employee Date

Print name

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