State of New Jersey Department of the Treasury Division of Pensions and Benefits Po Box 299 Trenton, Nj 08625-0299 State Employee Coverage Waiver/reinstatement State Health Benefits Program

Reinstatement of Coverage I previously waived State Health Benefits Program coverage because I had other health coverage. As of _____________________, I am no longer covered by the other health plan, request reinstatement of the State (date) Health Benefits Program coverage, and have provided proof of loss of the other coverage. I further understand that coverage is permitted as an employee, retiree, or dependent, however, multiple coverage under the State Health Benefits Program is prohibited.