Page 24 - 2022 DPR Construction Benefit Guide_Craft Employees

DPR CONSTRUCTION WAIVER OF MEDICAL COVERAGE
The following section must be completed if either the Employee or any Dependents are waiving medical coverage.

I certify that: Tear out at perforation.
I am declining coverage for myself
I am declining coverage for my spouse/domestic partner
I am declining coverage for my child/children
Reason for Waiving Coverage:

I am covered by my spouse’s plan. Insurer: __________________________________________ Policy Number: ______________________
I am covered by an individual health plan
Other: _____________________________________________________________________________________________________________
The available coverage and plans have been explained to me by DPR. I have been given the opportunity to apply for the available coverages.
I have decided not to enroll myself and/or my dependent(s). I understand that waiving health coverage now may result in the
imposition of late enrollment penalties, should I later elect to enroll for myself and/or dependents. Also, by declining
coverage, I acknowledge that I and/or my dependents may have to wait to be enrolled until the next Open Enrollment
Period or enroll within 30 days of a qualifying event.

Employee Signature Date

Please Read Carefully – Signature And Deduction

Authorization Required

I have received and read all materials explaining the DPR Construction benefit program. I understand that I am making a binding
election concerning my benefits for the entire plan year and may not be changed except as provided in the cafeteria plan
document. I hereby apply for and/or cancel insurance for which I and my eligible dependents have designated. Election changes
must be made within 31 days of any qualified status change. When available, contributions will be deducted from my pay on
a pre-tax salary deduction basis. If there is a change in premiums, the amount of my pre-tax benefit election will be adjusted
automatically. I understand that my benefit elections may continue in subsequent plan years. I also understand that this
agreement is subject to the terms and conditions of the benefit plans, as amended from time to time. I hereby request coverage
for the Group Insurance selection above for which I am or may become eligible and authorize DPR to make the necessary
deductions from my pay for the contributions required for the insurance coverage.
I attest by signing below that I have reviewed the information provided on this application and to the best of
my knowledge and belief; it is true and accurate with no omissions or misstatements.

Employee Signature Date

24