PO Box 1095 Kirksville, MO 63501 cva@charitonvalley.org Phone: 660-665-1111 Fax: 660-665-1409

Declining Coverage

If you are declining all coverage options, you will need to complete the following forms and indicate you are declining coverage. Please note, all Full-Time employees are enrolled in the company paid group Life/AD&D plan. You will need to indicate on the Anthem Enrollment form in section 7 your beneficiary information.

Anthem Enrollment Form (Please fill out your basic info, section 7 for Life/AD&D, and Section 11 waiver of coverage)

Payroll Election Form (Hourly Employee 24 pay periods) Please mark decline on the appropriate plan options

Payroll Election Form (Admin Exempt Employees 12 pay periods) Please mark decline on the appropriate plan options

 

Accessibility
Click to listen highlighted text!