REQUEST TO DECLINE AND WAIVE
MEDICAL HEALTH INSURANCE COVERAGE 

                              (Medical Buy-Out)  -  2009  Enrollment Form

1.  I,						, as an active benefits eligible employee, hereby request to decline and waive my Employer sponsored medical health insurance for the 2009 Plan Year (Jan. 1 � Dec. 31)  I understand that, during Plan Year 2009, I must be continuously covered by another medical health insurance plan to be eligible for waiver of Employer sponsored medical health insurance coverage.  Accordingly, I hereby certify that I will have coverage under the following medical health insurance plan for 2009:

Name of Health Insurance Plan for 2009: 										
This Coverage Belongs to: (Name of Enrollee) 										
 Source of Coverage: (Employer Name) 											                           
Your S. S. # :________-_________-__________	        Your spouse�s   S. S. # : _________-________-_________
Your spouse�s Name:							
Will all of your dependents, if any, have coverage under the above Plan? Yes____  No____
Is your spouse employed by O.C.C.C. or O.C. Government: Yes____  No____

 2.  In making this request for 2009, I understand and agree that I and/or my dependents will not be eligible for Employer provided medical health insurance coverage for which I and/or my dependents would otherwise be eligible.  Notwithstanding anything to the contrary in this form, I understand and agree that if I suffer an involuntary loss of this alternate coverage, I may apply to re-establish Employer provided medical health insurance coverage, as described in Item. 4, explained below. I hereby acknowledge that I must complete and submit this waiver form to the Human Resource Office, during the annual open enrollment period, for each year I want to waive medical health insurance coverage.  In the event that I do not submit a new form (for continuation of the medical health insurance buy-out) to the Office of Risk Management during the next open enrollment period, I shall automatically be enrolled in the Empire Plan, unless contractually prohibited, effective January 1st of the following calendar year.

3.  I understand and agree that I will be compensated by the Employer for my waiver of medical health insurance coverage in accordance with the terms of the applicable collective bargaining agreement.

4.  I understand and agree that my waiver of medical health insurance coverage shall remain in effect throughout the 2009 calendar year unless I suffer an involuntary loss of alternate coverage.  In order to re-establish the medical health insurance coverage provided by the Employer, I understand that I must complete and submit to the Human Resource Office a �Request to Resume Medical Health Insurance Coverage� and provide proof of the involuntary loss of coverage.  The effective date of re-establishment of my medical health insurance coverage shall be subject to and conditioned on the requirements of the Employer�s medical health insurance carrier(s) and the Human Resource Office.  In addition, I understand that these requirements may be changed at any time.   If I submit the form �Request to Resume Medical Health Insurance Coverage� to the Human Resource Office, and my request is granted, I agree to forfeit the buy-out payment due me for the quarter in which I resume medical health insurance coverage, and thereafter.

Employee Signature 									Date: 				

Print Name										         
													
=======================================================================================
APPROVED BY Human Resources:   Yes ______    No ______                     Date:			                   9/08