State Health Bene31ts Program SHBP chool Employees146 Health Bene31ts Program SEHBPCANCELDECLINEWAIVE RETIRED COVERAGE FORMMEMBER CERTIFICATION 150 I certify that all the information supplied on th ID: 895122
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1 Member Signature________________________
Member Signature__________________________________________________ Date ____/____/____ State Health Benets Program (SHBP) chool Employees Health Benets Program (SEHBP)CANCEL/DECLINE/WAIVE RETIRED COVERAGE FORM MEMBER CERTIFICATION I certify that all the information supplied on this form is true to the best of my knowledge. Misrepresentation: Any person that knowingly provides false or misleading information is subject to criminal and civil pen 3. For those who permanently do not want coverage check appropriate box. If you are newly eligible to enroll and wish to decline SHBP/SEHBP Medical and/or Dental coverage, check appropriate box. If you are declining only one type of coverage, you must also complete only, you will not be permitted to enroll in the SHBP/SEHBP Dental plans at a later date. Your enrollment in Medical coverage will not be If you are eligible for Medicare and wish to waive the SHBP/SEHBP Medicare Part D plan, you must attach written proof of your 2. FORMER EMPLOYER NAME______________________________________________________________ DATE OF RETIREMENT ______/______/______ 1. ( )/ / Indicate Marital Status as follows:(Married), (Domestic Partnership), (Divorced),(Widowed)MAIL COMPLETED APPLICATION TO: Trenton, NJ 08625-0299 Event Reason: Effective Date Location No. ______/______/______ FOR DIVISION USE ONLY