SIP Enrollment Form Step 1 of 6 0% General Instructions Section 1 is to be completed by the employer and Section 2 is to be completed by the employee. The Employee Name and Social Security number must be completed for all transactions. Additional Instructions for New Enrollments Employer – Complete the first four lines in Section 1. Employee – To enroll, complete Section 2 in full and sign the Accepting Coverage section after reading the statement below. To decline, sign the Declining Coverage section after reading the statement below. Additional Instructions for Changes Employer – Complete the Change in Section 1 including the date of the qualifying event and the nature of change. Employee – Complete only the information which has changed. For example, to report a marriage and add a spouse, complete the Marital Status, Coverage Elected for spouse, Spouse Name, Social Security Number, Sex, Birth Date, Employer Information and if the spouse has other coverage and Medicare eligibility. Sign the Accepting Coverage section. For a change of address, complete the new address and sign the Accepting Coverage section. Additional Instructions for Terminations Employer – Complete the Termination box in Section 1 including the Date of Termination and Effective Date. Section 1 - To Be Completed By EmployerEmployer: Kruse & Associates | Group # T327Location/Class Is this a new enrollment? Yes No Date of Hire MM slash DD slash YYYY Late Entrant Yes No Effective Date MM slash DD slash YYYY Is this a change? Yes No Employee Type Hourly Salaried Other Date of qualifying event MM slash DD slash YYYY Please indicate the nature of the change/qualifying event Is this a termination? Yes No Date of termination MM slash DD slash YYYY Effective Date MM slash DD slash YYYY Section 2 - To Be Completed by EmployeeEmployee Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last SS# Home Address Street Address Unit/Apt # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneGender Male Female Birth Date MM slash DD slash YYYY Plan Elected 1000 2000 2500 5000 MEC Marital Status Married Single Divorced Widowed Legally Separated Coverage ElectedCheck coverages desired in each category for yourself & the dependents listed belowEmployee Medical Dental Vision Other Spouse Medical Dental Vision Other Dependent Children Medical Dental Vision Other How many dependents need coverage? 0 1 2 3 4 5 1: Dependent Full Name Social Security # Sex Birth Date Relationship to you Spouse Child Other 2: Dependent Full Name Social Security # Sex Birth Date Relationship Child Spouse Other 3: Full Name (indicate the name(s) of your dependent(s) below) Social Security # Sex Birth Date Relationship Child Spouse Other 4: Dependent Full Name Social Security # Sex Birth Date Relationship Child Spouse Other 5: Dependent Full Name Social Security # Sex Birth Date Relationship Child Spouse Other Do you or your dependents have other medical and/or dental coverage? Yes NO If yes, who is covered? Type of coverage Medical Dental Both Name of carrier Are you or your dependents eligible for Medicare? Yes No Who is eligible? Is any applicant disabled/handicapped? Yes No Name of disabled/handicapped applicant If yes, please provide documentation. Accepting CoverageName of Employee Type your full name here to Sign this document I am enrolling for coverage under my employer’s health benefit plan Date MM slash DD slash YYYY Declining CoverageName of Employee If you wish to decline coverage because you have other coverage I waive health coverage for myself (and dependents, if any) and I have read and signed the waiver statement below.Having met the eligibility requirements, you are being offered the opportunity to enroll in health coverage offered by your Employer. You have the right to decline or waive coverage. If you do waive coverage for yourself, you may not cover dependents under the Employer’s health plan. Note that if you waive coverage considered affordable and minimum essential under the Patient Protection and Affordable Care Act (ACA), you will not qualify for government credits and subsidies to purchase individual health insurance in the marketplace. The decision to waive coverage has consequences for you. For example: If you waive this coverage and do not obtain coverage on your own, you will be subject to a penalty under the individual responsibility requirement of the ACA If you waive coverage, you cannot enroll in your Employer’s health plan until the next open enrollment, unless you experience a qualified change in status. Examples include if you are covered under another plan but that coverage is lost, or if you gain a new dependent through birth, adoption, or marriage. However, you must request to enroll in your plan within 30 days of the qualified change in status. If you miss the 30-day enrollment deadline, you must wait until open enrollment. I acknowledge that my Employer has offered me affordable minimum essential coverage, as defined under the ACA, that I have read the above and that I understand the consequences of my waiver of coverage.Representative of the Employer Type your full name here to sign this documentI received this Waiver of Coverage from the above employee on MM slash DD slash YYYY Δ
