Health Insurance Enrollment or Waiver

Health Insurance Enrollment or Waiver

Please answer the questions below so that we can send the relevant health insurance document(s) to the email address you provide on this form.
Please confirm your benefit eligibility on the benefits webpage before completing this form.

Also be sure to review the plan details on the website prior to enrolling.

If you are looking to waive health insurance provided by the City, please select the "I would like to NOT enroll in any plan." option in the responses to "Which plan are you looking to enroll in or modify?".
First Name
Last Name
Email
Please use your City email address if you have one. example@example.com
Department
Employee Status
You have to have a qualifying event to be eligible to modify your health insurance benefit. For a list of qualifying events click here.
Do you have a qualifying event?
You are not eligible to modify your health insurance benefit at this time. Outside of a qualifying event, your next opportunity will be during Fall Open Enrollment.
Qualifying Event File Upload

Please upload your qualifying event documentation.
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Attachment
Are you adding dependents to your health benefit?
Select no if you are not enrolling in health insurance and need a waiver form.
Birth Certificate(s) File Upload

Please upload a birth certificate or documentation of legal guardianship for each child you wish to add as a dependent on your health insurance plan.
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Marriage Certificate File Upload

Please upload your marriage certificate.
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Are you eligible for Medicare parts A and B?
Are you cancelling your health insurance benefit?
Which plan are you looking to enroll in or modify?
Please select the "I would like to NOT enroll in any plan." if you would like to waive health insurance with the City.
Which retiree plan are you looking to enroll in or modify?
Which Medicare eligible plan are you looking to enroll in or modify?
Medicare Card Upload

Please attach your Medicare card to confirm eligibility.
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Next Steps

After you click the Submit button below, we will send the relevant health insurance form(s) to the email address you provided on this form. It will come from "City of Cambridge Benefits Team via Adobe Acrobat Sign".

Once you complete and sign the document(s), the form(s) will be sent to Human Resources for eligibility review and processing. You will be given an option to download your completed form(s).

If you don't see the form(s) in your inbox within 10 minutes of submitting this form, please check your spam/junk folders. If you still do not see the form(s), please contact benefits@cambridgema.gov or call 617-349-1770.
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