Form Ha 0780 0707P PDF Details

Are you required to file Form 1040, but don't have the time or resources to do all the research it requires? With so many forms, schedules, and worksheets to gather information for, completing your taxes can be daunting. Luckily, there are a number of tax preparation services that can help make the process easier for you. This blog post will provide an overview of Form 1040 and some tips on how to find the best tax preparer for your needs. Keep reading for more information!

QuestionAnswer
Form NameForm Ha 0780 0707P
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesNJ_State_Health _Benefits_Waive r Reinstatement_Form ha 0780 0510p form

Form Preview Example

HA-0780-0707p

STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY

DIVISION OF PENSIONS AND BENEFITS

PO BOX 299

TRENTON, NJ 08625-0299

STATE HEALTH BENEFITS PROGRAM COVERAGE

STATE EMPLOYEE WAIVER/REINSTATEMENT

Part 1: To be completed by the employee. Please print.

1.Name __________________________________________________ SS# ____________________________________

Check one box below.

Waiver of Coverage

I agree to voluntarily waive State Health Benefits Program (SHBP) coverage to which I am entitled because I am covered under other health coverage. I understand that while coverage is waived, I will not be required to make payroll contributions required for medical and/or prescription drug coverage.

I understand that I may resume State Health Benefits Program coverage if I lose coverage under the other health coverage, provided that I notify the SHBP within 60 days of the loss of the other coverage and provide proof of loss of that coverage.

Reinstatement of Coverage

I previously waived State Health Benefits Program coverage because I had other health coverage.

As of _____________________, I am no longer covered by the other health plan, request reinstatement of the State

(DATE)

Health Benefits Program coverage, and have provided proof of loss of the other coverage.

Employee’s Signature __________________________________________ Date ________________________________

Part 2: To be completed by the employer. Check one box below.

We understand that this employee is requesting to voluntarily waive State Health Benefits Program coverage.

We request reinstatement of this employee’s State Health Benefits Program coverage.

A completed State Health Benefits Program Application must be attached to either a waiver or a reinstatement.

The reinstatement application must be filed within 60 days of the loss of other health coverage. If this timetable is followed, the coverage will be retroactive to the date of loss. If the 60 day time limit has passed, the employee must wait until the next open enrollment period to reenroll.

Employer Name _________________________________________ SHBP Location # ______________________

Signature of Certifying Officer _____________________________________________ Date _______________________