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Health Insurance Opt-Out Submission-April 2025

The Health Insurance Opt-Out Program is now open for submissions. Attached to this message are the program guidelines and form. Please review this important information.

A few things to keep in mind:

Forms must be submitted electronically through this portal to the EPS Human Resources Department no later than Friday, May 16, 2025, at 5 PM in order to receive a payout.
All required documentation must be included with the waiver form, or the request will be denied.
Waiver forms must be completed in full. If not, the payment will be delayed.
When submitting the waiver form, you must provide a letter or documentation from the health insurance carrier stating that you have active coverage through April 2025. This documentation must also provide the primary policyholder’s name. Providing an insurance ID card alone is not sufficient.
If you submit your forms after May 16, 2025, your opt-out will not be processed.

Please reach out to the EPS Human Resources Department with any questions.

For your reference, below are the Opt-Out Guidelines and Opt-Out Waiver Form.

City of Everett Health Insurance Opt Out Waiver Form

Health Insurance Opt Out Guidelines

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Email Address*

Answer required for "Email Address"

Employee ID Number*

Answer required for "Employee ID Number"

Everett Public Schools Location*

Answer required for "Everett Public Schools Location"

Employee Job Tilte*

Answer required for "Employee Job Tilte"

Health Insurance Carrier Name*

Answer required for "Health Insurance Carrier Name"

Health Insurance Primary Policy Holder Name*

Answer required for "Health Insurance Primary Policy Holder Name"

Group Number*

Answer required for "Group Number"

Effective Date of Health Insurance*

Answer required for "Effective Date of Health Insurance"

Proof of Insurance (Must be dated April or May 2025)*

Answer required for "Proof of Insurance (Must be dated April or May 2025)"

Choose a file or drag it here.

Opt Out Program Waiver*

Answer required for "Opt Out Program Waiver"

Choose a file or drag it here.