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Get Massachusetts Health Insurance Buyout Form

Er Insured Name First MI Last State Zip Code Street Address City 1. I hereby elect a monetary allowance in lieu of a Group Insurance Commission sponsored group health insurance plan. I understand that the allowance will be paid monthly in twelve equal payments. I understand that I must be a state employee or retiree to receive these payments; municipal enrollees are not eligible. I understand that taxes will be withheld from these payments. 2. I was covered by a Group Insurance Commission.

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