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WAIVER OF MEDICAL COVERAGE ELECTION FORM The undersigned employee who is eligible for coverage under the health insurance provided by the Euclid City School District hereby elects To waive all coverage under the medical and prescription insurance Contribution in lieu of such coverage. The undersigned hereby certifies that he or she is currently eligible for health insurance coverage through his or her spouse. This Form must be completed and filed with the District s Benefits Department/Lauri Johnston no later than thirty 30 days prior to the start of the Plan Year for which this election is intended to be effective. If you do not complete and file this Form with the District s Benefits Department on or before such deadline then you shall not be entitled to receive the School District Cash Contribution regardless of whether you have enrolled for coverage under the health insurance provided by the District. Note To be effective for the Plan Year beginning September 1 2013 this Form must be completed and filed no later than August 31 2013. The amount of the School District Cash Contribution for the Plan Year beginning September 1 2013 shall be 500 per year payable September 2014. All terms and conditions of the Waiver of Coverage Plan Component which is a part of the District s Section 125 Plan apply to your election* Employee Date signature Print name For District Use Only Received by. The undersigned hereby certifies that he or she is currently eligible for health insurance coverage through his or her spouse. This Form must be completed and filed with the District s Benefits Department/Lauri Johnston no later than thirty 30 days prior to the start of the Plan Year for which this election is intended to be effective. This Form must be completed and filed with the District s Benefits Department/Lauri Johnston no later than thirty 30 days prior to the start of the Plan Year for which this election is intended to be effective. If you do not complete and file this Form with the District s Benefits Department on or before such deadline then you shall not be entitled to receive the School District Cash Contribution regardless of whether you have enrolled for coverage under the health insurance provided by the District. If you do not complete and file this Form with the District s Benefits Department on or before such deadline then you shall not be entitled to receive the School District Cash Contribution regardless of whether you have enrolled for coverage under the health insurance provided by the District. Note To be effective for the Plan Year beginning September 1 2013 this Form must be completed and filed no later than August 31 2013. Note To be effective for the Plan Year beginning September 1 2013 this Form must be completed and filed no later than August 31 2013. The amount of the School District Cash Contribution for the Plan Year beginning September 1 2013 shall be 500 per year payable September 2014. The amount of the School District Cash Contribution for the Plan Year beginning September 1 2013 shall be 500 per year payable September 2014. All terms and conditions of the Waiver of Coverage Plan Component which is a part of the District s Section 125 Plan apply to your election* Employee Date signature Print name For District Use Only Received by.

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