Get Buy Out Waiver Program

The Buy Out Waiver Program allows eligible employees to waive their City health benefits in exchange for an incentive payment. This guide provides a step-by-step approach to filling out the necessary online form to ensure a smooth enrollment process.

Follow the steps to successfully complete the Buy Out Waiver Program form online.

1. Click ‘Get Form’ button to acquire the Buy Out Waiver Program Enrollment/Change Form and open it in an online editor.
2. Fill in your personal information in Section I, including your last name, first name, middle initial, social security number, home address, phone numbers, email, and agency name. Ensure that all details are accurate to avoid processing delays.
3. In Section II, indicate your intention to participate in the Buy Out Waiver Program by selecting one of the coverage options: Individual Coverage, Domestic Partner/Civil Union Coverage, or Family Coverage. Attach proof of your non-City group health coverage.
4. If you are terminating your participation, check the option to withdraw from the program and complete the additional required form for reinstating City health benefits.
5. If applicable, complete Section III for mid-year qualifying events that may affect your benefits. Ensure to list the event and provide legal or supporting documentation with your submission.
6. Sign and date the form in Section IV, affirming that you have read the materials and that you meet the qualifications to enroll or withdraw. Ensure your signature is legible.
7. Submit the completed form along with any required documentation to your agency's Human Resources Department or designated office according to the instructions provided.

Complete your Buy Out Waiver Program document online today to secure your health benefits waiver.