2017-18 Employee Benefits Acknowledgment Form
1. By signing this acknowledgement form, you understand that your employer is offering you and your eligible dependents health coverage, and that you have the right to participate or decline to participate in the plan. You acknowledge that the coverage being offered to you and your dependents is affordable, and offers minimum essential coverage as defined under the Affordable Care Act.
2. You understand that you must submit any request to elect or change coverage by completing an online enrollment form, or a paper enrollment form, and submitting to Integra Insurance Services within the eligibility window indicated in the 2017-18 Benefits Program.
3. You understand that any request to elect or change coverage must be submitted during one of the following:
During New Hire Eligibility: before your 60th day of full-time employment, with elections being effective the first day of the month following your 60th day of full-time employment, not to exceed 90 days.
During Annual Enrollment: before the deadline date indicated in the 2017- 18 Benefits Program. You understand that if you have questions with the indicated deadline requirement, or if you are not sure where to find the deadline date, you should contact Integra Insurance Services or HR.
It is your resonsibility to ensure that any request you've made to elect benefits has been received and processed.
4. You understand that by not submitting a completed 2017-18 Enrollment & Waiver form within the guidelines indicated above and in the 2017-18 Benefits Program, you are thereby waiving your right to participate or make changes in the 2017-18 Benefits Program as part of your enrollment eligibility. You understand that any decision to waive coverage has consequences for you and any eligible dependents, including the following:
- 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 the 2017-18 Benefits Program until the next open enrollment, unless you experience a qualified change in status.
5. You acknowledge that you have been provided with a 2017-18 Benefits Program and understand your rights to participate or not participate in the plan. You understand that you can contact Integra Insurance with any questions related to the benefits being offered to you.