Qualifying period 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by reviewing the Qualifying Life Events section. Familiarize yourself with the events that allow you to change your benefit coverage.
3. In the waiver section, select the reason for declining enrollment by marking the appropriate box. Options include being covered under another insurance plan or financial constraints.
4. Sign and date the form in the designated areas to confirm your decision. Ensure your printed name and home address are clearly filled out.
5. If applicable, have your Head Start Center Director or Bookkeeper complete their section, including signature and date.
6. Once completed, save your changes and download a copy for your records before mailing the original form to the specified address.

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