Form Bn0139-0513 - Decline Coverage Acknowledgement Form printable pdf download

DECLINE COVERAGE ACKNOWLEDGEMENT FORM

YOUR EE#______________

CHECK THE BOX THAT APPLIES TO YOU

DECLINE HEALTH COVERAGE – COVERED AS THE DEPENDENT OF ANOTHER COSTCO EMPLOYEE

I am a benefit eligible Costco employee who qualifies and is enrolled in health coverage as a dependent of another benefit

eligible Costco Employee:

Employee I am covered under ________________________________ Their EE # _________

•

I will receive health coverage as elected by the above employee.

•

I will receive Basic Life, AD&D, and Long Term Disability Insurance.

•

I may elect to participate in the Health Care Reimbursement Account and Dependent Care Assistance Plan, as well

as Supplemental Life Insurance, Supplemental AD&D Insurance and Long Term Care Insurance. I must elect these

benefits according to the rules and time periods described in the SPD for the Costco Benefits Program.

DECLINE WITH ANCILLARY COVERAGE (COVERED UNDER ANOTHER PLAN)

I decline coverage under Costco’s Health plans and elect to pay for LTD plan coverage. Premiums for LTD coverage will be

withheld from my wages on a pre-tax basis.

•

I authorize Costco to deduct the premiums for this benefit from my wages on a pre-tax basis. The premium is $10.00

per pay period if hired before 1/1/13 or $13.00 per pay period if hired on or after 1/1/13.

•

I will receive Basic Life and AD&D Insurance coverage.

•

I may elect to participate in the Health Care Reimbursement Account and Dependent Care Assistance Plan, as well

as Supplemental Life Insurance, Supplemental AD&D Insurance and Long Term Care Insurance. I must elect these

benefits according to the rules and time periods described in the SPD for the Costco Benefits Program.

DECLINE ALL COVERAGE

I decline all Program coverage.

•

I will not have any coverage under the Program for health care, Life Insurance, AD&D Insurance, Long Term

Disability Insurance, or Long Term Care Insurance.

•

I may not elect to contribute to the Health Care Reimbursement Account or Dependent Care Assistance Plan.

•

I may not change the benefit elections on this form until the next annual Open Enrollment, unless I experience a

qualified change in status (as defined by the Program)

I understand that different eligibility and enrollment rules apply to Voluntary Short Term Disability (STD). Once I am eligible for

STD, I must complete a different form to opt out of STD coverage.

I have read the Summary Plan Description and Enrollment Materials for the Costco Employee Benefits Program and I

understand my rights to benefits under the Program. I hereby knowingly and voluntarily elect to decline coverage under the

Program as designated herein. I have had sufficient time to consider this waiver and I agree that I will not hold Costco or the

Program responsible if it turns out that declining coverage under the Program was not to my advantage.

________________________________________

________________________________

Employee Name (Printed)

Employee Number

________________________________________

________________________________

Employee Signature

Date

BN0139-0513

DECLINE COVERAGE ACKNOWLEDGEMENT FORM

Form Bn0139-0513 - Decline Coverage Acknowledgement Form

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