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Get MA Employee Health Insurance Responsibility Disclosure Form

G this form because you have declined to participate in your employer sponsored health insurance plan and/or have declined to participate in the employer’s “Section 125 Cafeteria Plan” pre-tax purchasing arrangement. A Section 125 Plan is not health insurance; it is a way to purchase health insurance on a pre-tax basis. For information about affordable health insurance options, visit the Commonwealth Connector at < www.mahealthconnector.org >. Employers: please complete this section. See r.

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