Health Insurance Opt-out

Health Insurance Opt-out Program Application

Thanks for your interest in the health insurance opt-out program. This program is being offered in an effort to reduce the cost of the Town’s Health Insurance premium costs. The incentive will be offered to enrollees that have received health insurance benefits through the Town for the immediate prior 12 months.

You will need to upload the following documents as part of the application. Please have them completed and ready to submit.

Health Insurance Responsibility Disclosure Form (HIRD)
Written documentation of alternative health insurance covered outside of the Town’s group plans on employer letterhead

If you have any questions or trouble filling out the application, please contact Joan Chase, Human Resources Analyst at chasej@grafton-ma.gov or 508-839-5335 x1129.

1. Contact Information

First Name *This question is required.

Last Name *This question is required.

Email Address *This question is required.

Phone Number *This question is required.

2. I certify that I am an active employee for the Town of Grafton ("Town") and was covered by Town’s health insurance plans for the immediate prior 12 months. I hereby acknowledge that I have been advised of my right to enroll in health insurance coverage through the Town of Grafton. Having been so advised, I do hereby waive my right to health insurance coverage through the Town and I authorize the Town to cancel my existing health insurance coverage. *This question is required.

3. Date of voluntary cancellation: *This question is required.

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