Group Name:

Group Name: Group Policy Number (if known) Employee Name: Marital Status: Single Date of Employment: Date of Birth: New York Health Benefits Waiver of Coverage UnitedHealthcare Oxford Making Address: Oxford Enrollment Dept. • 14 Central Park Drive • Hooksett, NH 03106 • 1-888-201A216 DcteeeA) K T,,dyKe PLI_C Lesley e 6Roff 'Married diaO0? 00 2 9//96tc O Widowed K Divorced I am employed by and working at least 20 hours per week for the group shown above. I was given the opportunity to enroll in the Oxford* group health benefits plan(s) offered by my employer and I refuse coverage. Reason for Refusal (please check all appropriate boxes) I have other coverage from: iss My spouse's employer • Medicare Ll Medicaid LI Veteran's Administration • Union health plan • Another carriers group health plan sponsored by this employer U Another source of coverage (please specify): REQUIRED INFORMATION: LA h.) i yet) Name of Carrier Pc "J Other reason (please explain): I certify that all i /formation provided in this form is true and complete. By refusing group health benefits, I acknowledge that I and/or my de dent( )) may have to wort 'I the plan's next anniversary date to be enrolled for group cover ge. 7 2111.1i AA 2 /3 hois S t f Employee Date O2// _34 ) 0/3 Sign V ure of Benefits Administrator Date • Oxford HMO products ate underwritten oy Oxford Heath Plans (NY), Inc Oxford insurance products are underwritten by Oxford Health Insurance, Inc Copyright C) 2011 Oxford Health Plans LLC. Al' rights reserved NY-11-929 OHUOHP NY waiver 3313 Rev 7 EFTA00313626