SIP Enrollment Form

Step 1 of 6

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 Employer

Employer: Kruse & Associates | Group # T327

Location/Class

Is this a new enrollment?

Yes

Date of Hire

Late Entrant

Yes

Effective Date

Is this a change?

Yes

Employee Type

Hourly

Salaried

Other

Date of qualifying event

Please indicate the nature of the change/qualifying event

Is this a termination?

Yes

Date of termination

Effective Date

Section 2 - To Be Completed by Employee

Employee Name

Prefix First Middle Last

SS#

Home Address

Street Address Unit/Apt # City State ZIP Code

Phone

Gender

Male

Female

Birth Date

Plan Elected

1000

2000

2500

5000

MEC

Marital Status

Married

Single

Divorced

Widowed

Legally Separated

Coverage Elected

Check coverages desired in each category for yourself & the dependents listed below

Employee

Medical

Dental

Vision

Other

Spouse

Medical

Dental

Vision

Other

Dependent Children

Medical

Dental

Vision

Other

How many dependents need coverage?

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

If yes, who is covered?

Type of coverage

Medical

Dental

Both

Name of carrier

Are you or your dependents eligible for Medicare?

Yes

Who is eligible?

Is any applicant disabled/handicapped?

Yes

Name of disabled/handicapped applicant

If yes, please provide documentation.

Accepting Coverage

Name of Employee

Type your full name here to Sign this document

I am enrolling for coverage under my employer’s health benefit plan

Date

Declining Coverage

Name 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 document

I received this Waiver of Coverage from the above employee on