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FOR LIB USE ONLY Form LG04 Revised 10/15 LOCAL GOVERNMENT HEALTH INSURANCE PROGRAM 2016 DECLINATION OF COVERAGE FORM Date: Initials: SUBSCRIBER INFORMATION (Please print or type.) Name (First, Middle

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How to fill out lghip declination of coverage

How to fill out LGHIP declination of coverage:

01

Obtain the LGHIP declination of coverage form, which can usually be found on the official website of the LGHIP or through your employer.

02

Provide your personal information, including your full name, address, phone number, and email address. Make sure to double-check the accuracy of this information.

03

Indicate the reason for declining coverage. There are typically several options to choose from, such as being covered by another insurance plan or not wanting to participate in the LGHIP.

04

If you are declining coverage due to having another insurance plan, provide details about that plan, including the name of the insurance company and any policy numbers or group numbers associated with it.

05

Sign and date the form. Make sure to read through all the terms and conditions before signing to ensure that you fully understand the consequences of declining coverage.

06

Submit the completed form as instructed on the form itself, usually by mailing it to the provided address or submitting it online if an electronic option is available.

Who needs LGHIP declination of coverage:

01

Employees who are eligible for coverage under the LGHIP but choose not to enroll in the program.

02

Individuals who have alternative insurance coverage through a spouse, another employer, or a private health insurance plan and do not wish to participate in the LGHIP.

03

Dependents who are eligible for coverage but opt out because they have coverage through another source.

Note: It is important to consult the specific guidelines and instructions provided by the LGHIP or your employer to ensure that you accurately fill out the declination of coverage form.

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What is lghip declination of coverage?

The lghip declination of coverage is a form that individuals fill out if they choose not to enroll in or maintain minimum essential health coverage.

Who is required to file lghip declination of coverage?

Individuals who do not have minimum essential health coverage are required to file lghip declination of coverage.

How to fill out lghip declination of coverage?

The lghip declination of coverage form can be filled out online or by mail, and requires the individual to provide personal information and attest to their lack of coverage.

What is the purpose of lghip declination of coverage?

The purpose of lghip declination of coverage is to ensure that individuals without health insurance are aware of the potential penalties for not having coverage.

What information must be reported on lghip declination of coverage?

The lghip declination of coverage form requires information such as the individual's name, address, social security number, and reasons for not having health coverage.

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