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Form – 2021-2022 Plan Year Offer of Health Coverage Acknowledgement
Form – 2021-2022 Plan Year Offer of Health Coverage Acknowledgement
Robin Saxton
2021-09-12T11:13:05-04:00
Benefits Offer Acknowledgement
Date
Employee Name:
*
Authorization
I acknowledge that I have been offered health coverage by my employer HomeCentris for the benefit period ending on September 30, 2023. I have been given a summary of the health benefits offered and the employee contribution amount required to receive health coverage. I also understand that my election (to waive or enroll in health coverage) is irrevocable (cannot be reversed) for the benefit period ending on September 30, 2023, unless I experience an event (qualified life event) which allows me to make a midyear election change.
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