2019 Jenison Public Schools Insurance Election Form - WMHIP Group
Email address *
Employee's First Name *
Your answer
Employee's Last Name *
Your answer
F. T. E. (Part Time Only)
Please indicate the percentage in your answer
Your answer
Health Insurance Waiver
I elect the following with respect to the coverage for which I am eligible under the group health plan sponsored by Jenison Public Schools ("Health Plan"). I understand that if I waive coverage, my compensation will be increased for the plan year to which the waiver applies in an amount established in the collective bargaining agreement, employment contract or terms of employment (whichever applies). I also understand that I am only eligible for the cash in lieu payment if I can attest that I have alternative minimum essential coverage for myself, spouse, and dependents other than coverage obtained in the individual market as stipulated in the Affordable Care Act Provisions.
You Must Check One: *
Effective Date
MM
/
DD
/
YYYY
Next
Never submit passwords through Google Forms.
This form was created inside of JPS. Report Abuse - Terms of Service