Waiving Medical Coverage Questionnaire

To waive your medical coverage you must:

  • Complete the Waiver of Medical Coverage Form.
  • Send proof of other coverage. Requirements are listed on the form.
  • Meet your deadline. SEGIP must receive your Waiver of Medical Coverage Form and proof of other coverage within your 30-day eligibility period or the print date on your enrollment packet, whichever is later.
Waiver of Medical Coverage Form


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