Page 130 - Tampa Bay Rays 2022 Flipbook

2022 Voluntary Opt-Out of Health Insurance Coverage

If you have the ability to obtain health insurance from another source such as your spouse or a previous employer, the
Tampa Bay Rays or Rowdies will pay you a bonus for voluntarily opting-out of our health insurance coverage.

In return for proof of other credible health insurance coverage and my agreement to voluntarily opt-out, I am now eligible
for one of the following bonuses:

 Employee Opt-out – $1,500 – if you voluntarily opt-out
 Child(ren) Opt-out – $3,500 – if your children voluntarily opt-out
 Spouse Opt-out – $3,500 – if your spouse voluntarily opts-out
 Spouse and Child(ren) Opt-out – $3,500 – if your spouse and your children voluntarily opt-out
 Employee and Child(ren) Opt-out – $5,000 – if you and your children voluntarily opt-out
 Employee and Spouse Opt-out – $5,000 – if you and your spouse voluntarily opt-out
 Employee, Spouse and Child(ren) Opt-out – $5,000 – if you, your spouse and your children voluntarily opt-out

You are not eligible for a bonus under the following scenarios:
• Death or divorce of a spouse

• Child who reaches the maximum allowable age to be covered as a dependent
• You do not have credible coverage but your spouse and/or dependent children do
• You elect any tier of coverage in the 70% Minimum Value Plan

To qualify, please complete the section below and return to the Human Resources department, along with proof of
other credible health insurance coverage (i.e. a letter on Employer or Group letterhead identifying all covered
members, the effective date of coverage and signed by an authorized representative). Once all of the necessary
paperwork is received and verified, your voluntary opt-out bonus will be divided by your total number of pay periods for
2022 and that amount will be added to each of your corresponding paychecks. If you terminate employment prior to the
end of the calendar year, you will forfeit this bonus and the Rays will not pay any amounts for months after you terminate
employment. This is processed as a bonus and will expire at the end of each calendar year and requires re-verification
of the aforementioned items.

Employee Name

Social Security #

I hereby acknowledge that I have been advised of my right to have health insurance coverage through the Tampa Bay
Rays or Rowdies. Having been so advised, I do hereby waive my right to health insurance coverage and/or cancel my
health insurance coverage. I also authorize the Tampa Bay Rays or Rowdies to cancel my existing health insurance
coverage (if applicable) as of January 1, 2022.

I hereby certify that there is no outstanding court order or agreement requiring me to provide health insurance coverage
for my spouse and dependent children, if any.

I hereby acknowledge that the Tampa Bay Rays or Rowdies are not responsible for my health insurance coverage effective
on January 1, 2022 and for each calendar year thereafter that I voluntarily agree to opt-out of health insurance coverage
and provide qualifying documentation.

I hereby acknowledge that I may only obtain health insurance through the Tampa Bay Rays or Rowdies or Rowdies in the
future, outside of open enrollment, if my alternate health insurance coverage is canceled, lost or otherwise terminated,
or I experience a qualifying event under the HIPAA special enrollment rules, and I provide documentation of such event
to the HR department within thirty (30) days of the cancellation of coverage. I also agree that I must repay a prorated
amount of the annual voluntary opt-out payment to reflect the period for which I will receive health insurance from the
Tampa Bay Rays or Rowdies or Rowdies.

I acknowledge that I have read and understand the information contained on this waiver form concerning the terms and
conditions of the Tampa Bay Rays or Rowdies or Rowdies voluntary opt-out program.

The Tampa Bay Rays or Rowdies or Rowdies reserve the right to make changes to this voluntary opt-out program at any
time.

Signature Date