Health Benefits Waiver

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Date*
Name*
Consent*
I decline my employer’s offer of coverage for the following reason. I have:
I decline my employer’s offer of coverage for the following reason. I have:

Your Name Here
NOTES -Your employer offers a medical plan that meets the ‘affordable limits’, therefore you are not entitled to any premium subsidy (please see the Marketplace Notice Delivered by your employer)
-Individual marketplace insurance plans typically have smaller networks than employer-sponsored plans.
-Premium payments for individual marketplace insurance plans are the employee’s responsibility to pay.
-Your employer does not contribute to any individual marketplace insurance plans purchased by you.
-Premium payments made by you for an individual exchange insurance plan is paid with after-tax dollars.
-Premium contributions towards your employer’s plan are deducted from pay on a pre-tax basis

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