I hereby notify the Baldwin-Whitehall School District that I wish to waive my participation in the District's group insurance plans, as follows, in lieu of a supplemental payroll payment.  Such payment will be made in accordance with the Compensation/Benefit Policy.

This waiver will remain in effect for the entire 2024-2025 school year.  I understand that during this period, I may not rejoin the plan for any reason except as follows:

Loss of eligibility for other coverage (Refer to the HIPAA Notice of Special Enrollment Rights.)

o   Due to divorce or legal separation;
o   Dependent loss of eligibility due to age under a parent’s plan;
o   Death of an employee’s spouse which leaves the spouse with no coverage;
o   Spouse’s loss of employment that terminates insurance coverage; and
o   Spouse no longer eligible for insurance coverage for other reasons.

You must request enrollment within 30 days after your or your dependents’ other coverage ends.

At the end of this 2024-2025 waiver period, you may either rejoin the plan or waive your coverage for the next school year.  

*A letter/document (not insurance card) from the employer of your spouse/parent must be sent to Georgann Helman at Administration stating that you are enrolled in Medical, Dental, Vision (that applies) plus the type of coverage (Individual, Family, etc.) listing all the names that are covered.

Questions:  Contact Georgann Helman at 412-884-6300, Ext. 7461.