REQUEST TO DECLINE AND WAIVE
MEDICAL HEALTH INSURANCE COVERAGE


 
(Applicable only to CSEA (as well as Managerial/Confidential and Management Plan Employees), 
OCCC Faculty Association, OCCC Staff & Chairmen�s Association 
(Medical Buy-Out)


1. I, , hereby request to decline and waive medical 
health insurance provided by the Employer for which I am presently eligible. I understand that I must be covered by 
another medical health insurance plan to be eligible for waiver of Employer medical health insurance coverage. 
Accordingly, I hereby certify that I am presently covered by the following medical health insurance plan: 
Name of Health Insurance Plan for 2005: 

Coverage provided by or through: 

Your S. S. # :________-_________-__________ Your spouse�s S. S. # : _________-________-_________ 

Your spouse�s Name: 

Is your spouse employed by O.C.C.C. or O.C. Government: Yes____ No____ 

You MUST attach to this form: 
A letter to verify that you will be covered under this insurance for 2005 

If your spouse is employed by O.C.C.C. or O.C. Government, Risk Management will verify coverage. 

2. In making this request, 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 are now eligible. Notwithstanding anything to the 
contrary in this form, I understand and agree that I may apply to re-establish Employer provided medical health insurance 
coverage only on the Employer form �Request to Resume Medical Health Insurance Coverage�, and that the effective 
date for resumption of medical health insurance coverage by the Employer is subject to and conditioned on the 
requirements of the medical health insurance carrier(s). In addition, I understand that those requirements may be changed 
at any time by the medical health insurance carrier(s). I hereby acknowledge that this form is to be completed and 
submitted to the Office of Risk Management annually by me, during the open enrollment period, for the ensuing year. In 
the event that I do not submit this form to the Office of Risk Management during the open enrollment period, I 
shall be automatically enrolled in the Empire Plan, 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 for the ensuing 
calendar year unless I complete and submit to the Office of Risk Management the Employer form �Request to Resume 
Medical Health Insurance Coverage� in order to re-establish the medical health insurance coverage provided by the 
Employer in accordance with the requirements of the Employer's medical health insurance carrier(s). The effective date of 
re-establishment of my medical health insurance coverage shall be as provided by the Employer�s medical health 
insurance carrier(s). If I submit the form �Request to Resume Medical Health Insurance Coverage� to the Office of Risk 
Management, and my request is granted, I agree to forfeit the buy-out payment due me for the quarter in which I have 
requested to resume medical health insurance coverage, and thereafter. 
Employee Signature Date: 

Print Name 

======================================================================================= 
APPROVED BY Risk Management: Yes ______ No ______ Date: 

Risk Management, 30 Matthews St. Suite 101, Goshen, NY 10924 Telephone 291-2139