Get Health Insurance Opt-out Election Form For New Enrollees

This guide provides clear, step-by-step instructions for filling out the Health Insurance Opt-Out Election Form For New Enrollees online. Whether you are new to the process or need a refresher, this comprehensive guide will support you in successfully completing the form.

Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the Health Insurance Opt-Out Election Form and open it in the online editor.
2. Begin filling out the form by entering the insured's name, including the first name, middle initial, and last name in the appropriate fields.
3. Next, provide the street address, city, state, and zip code in the designated areas to ensure proper identification.
4. Fill in your email address to facilitate communication regarding your election status.
5. Select the number of pay periods with Melrose (21, 26, 42, or 52), noting how often you receive pay.
6. Indicate your choice to elect a monetary allowance instead of participating in a City of Melrose sponsored group health insurance plan by checking the appropriate box.
7. Confirm that you have compared the alternate health insurance coverage with your City of Melrose coverage by checking the required box.
8. Specify the type of coverage (either ‘Individual’ or ‘Family’) by marking the corresponding option.
9. List the current health plan you are enrolled in, providing necessary details for reference.
10. Ensure you have attached acceptable proof of coverage to the form before submission.
11. If applicable, confirm that you have completed the GIC Form 1MUN to terminate your current health coverage.
12. Review the conditions that allow you to cancel this election, ensuring you understand your eligibility under specific circumstances.
13. Sign the form to acknowledge that you have read the procedures and policies associated with the opt-out election.
14. Finally, save your changes, and choose to download, print, or share the completed form as needed.

Get started now and complete your Health Insurance Opt-Out Election Form online.