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HEALTH INSURANCE COVERAGE INFORMATION
CAS Steel Erectors, LLC offers a Health Insurance Coverage plan after an initial 90 day consecutive probationary period of employment. The cost to the employee is 50% of the monthly policy premium which is pulled from employee's weekly paycheck. Please see the current Health Insurance Costs for the program options as a download on this website under Employment Forms for further details. Then complete this Health Insurance Coverage Enrollment or Waiver form.
This is a mandatory form to either request the current Health Insurance Coverage Plan offered by CAS Steel Erectors or to decline coverage. You must choose one or the other.
Acceptance or Waiving of Health Insurance Coverage
(Required)
Yes, I would like to enroll in Health Insurance coverage. Please send me the Enrollment Application.
No, I would like to decline Health Insurance Coverage from CAS Steel Erectors, LLC at this time.
I decline all coverage for:
(Required)
Myself
Spouse
Dependent Children
Myself and all dependents
I am declining coverage due to the following:
(Required)
Spouse's Employer's Plan
Covered by Medicare
COBRA from Prior Employer
Tri-Care
Individual Plan
Medicaid
VA Eligibility
I (we) have no other coverage at this time
Other
Consent (Must Check box)
Yes, I would like to enroll in Health Insurance coverage with CAS Steel Erectors. I understand that there is a 90 day consecutive probationary period prior to addition of the Health Insurance coverage and that I am responsible for paying 50% of the Health Insurance premium to be deducted in a weekly figure from my paychecks beginning at time of enrollment. Please send me the Enrollment Application Form to complete.
Consent (Must Check box)
No, I do not wish to add Health Insurance at this time. I understand that by waiving coverage at this time, I will not be allowed to join the healthcare plan unless I qualify at a special enrollment period, as a late enrollee (if applicable) or at the next open enrollment time period.
Name
(Required)
First
Last
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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