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HEALTHCARE POLICY & BENEFIT SERVICES DIVISIONCO1304 (revised 1/2012)WAIVER OF RETIREE HEALTH PLAN PARTICIPATION, hereby waive my right to participate in the State of Connecticut retiree health insurance/medical
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How to fill out waiver of retiree health

01
Read the instructions on the waiver form carefully.
02
Fill out all necessary personal information, such as name, address, and contact details.
03
Indicate the reason for the waiver request.
04
Provide any supporting documents or evidence, if required.
05
Review the filled form for accuracy and completeness.
06
Sign and date the waiver form.
07
Submit the filled form to the appropriate authority or department.

Who needs waiver of retiree health?

01
Retirees who are eligible for the retiree health benefit but wish to voluntarily waive or opt out of it.
02
Retirees who have alternate health coverage from another source.
03
Retirees who reside in a country where the retiree health benefit is not applicable or accessible.

What is WAIVER OF RETIREE HEALTH PLAN PARTICIPATION Form?

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A waiver of retiree health is a formal document stating that an individual is choosing to opt out of the health insurance provided by their former employer.
Retirees who are eligible for health insurance coverage through their former employer but choose not to enroll in the plan may be required to file a waiver of retiree health.
To fill out a waiver of retiree health, individuals typically need to provide their personal information, details about their current health insurance coverage, and sign the document to confirm their decision.
The purpose of a waiver of retiree health is to formally indicate that an individual is declining the health insurance coverage offered by their former employer.
The waiver of retiree health may require individuals to disclose their current health insurance coverage, reason for opting out of the employer-provided plan, and other relevant personal information.
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