OPT-OUT CAFETERIA PLAN ELECTION FORM 2015-2016 I wish to participate in the Opt-Out Cafeteria Plan (the “Plan”) and receive cash payments in lieu of coverage. I elect to “Opt Out” of insurance coverage available through Irvington Board of Education (the “Employer”), as noted, for the period July 1, 2015 through June 30, 2016.     Single Medical Single Prescription Single Dental Single Vision $1,000.00 $500.00 $0 $0     Family Medical Family Prescription Family Dental Family Vision $2,000.00 $1,000.00 $0 $0 Attach written proof of other coverage (letter from HR/Benefits Department or Certificate of Coverage from Insurance Carrier with all dependents listed. A copy of health insurance ID card will not be accepted. In connection with my participation in the Plan, I fully understand and certify the following:       The election to waive coverage under the Plan is entirely voluntary. The IBOE does not encourage any employee to receive cash in lieu of adequate health and prescription insurance coverage. I have qualifying, alternate health and/or prescription drug coverage and have provided written proof certifying the same. I understand that payments made to me under the Plan are taxable income. I understand that if I wish to enroll in the Employer’s plans at a later date, I will be subject to the Plan’s enrollment rules. I understand that I must re-apply each year during the Open Enrollment to continue participation. I understand that I must opt out of all plans (health, prescription, dental and vision) or the Employee Cost Share provisions of Chapter 78 will apply. Employee Name (please print) School/ Department Employee Signature Date Phone For HR Use Only     Acceptable proof of other coverage received Past participant New participant – confirm IBOE coverage terminated Comments: ______________________________________________________________________________________________ ________________________________________________________ HR/Benefit Approval