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Resolution of the Mayor and Council of Princeton to Terminate All Participation Under the SHBP and SEHBP (including prescription drug plan and/or dental plan coverage)
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BE IT RESOLVED:
1. The Municipality of Princeton______ 814000 & 814001______________________
Corporate Name of Employer SHBP/SHEBP Employer Location Number
2. hereby resolves to terminate its participation in the Program (Medical Plan, Prescription Drug Plan, and/or Dental Plan coverage) thereby canceling coverage provided by the SHBP and/or SEHBP (N.J.S.A. 52:14-17.25 et seq.) for all its active and retired employees.
3. We shall notify all active employees of the date of their termination of coverage under the Program.
4. We understand that the New Jersey Division of Pensions & Benefits (NJDPB) will notify retired employees of the cancellation of their coverage.
5. We understand that all COBRA participants will be notified by the NJDPB and advised to contact our office concerning a possible alternative health, prescription drug, and dental insurance plan.
6. We understand that this resolution shall take effect the first of the month following a 60-day period beginning with the receipt of the resolution by the State Health Benefits Commission or School Employees’ Health Benefits Commission.
I hereby certify that the foregoing is a true and correct copy of a resolution duly adopted by the:
Municipality of Princeton (609) 924-5176 __________________________________________________________________________
Corporate Name of Employer Phone Number
400 Witherspoon Street Princeton NJ 08540
Street Address City Sate Zip Code
Bernard P. Hvozdovic, Jr. Administrator bhvozdovic@princetonnj.gov
Print Name Official Title Email Address
________________________________________________________________/______/______ Signature Date
235 30-0746654______________________________________
Number of Employees Employer’s State Employer Identification Number (EIN)
Please complete and comply with the following:
Type of funding method with the new contract:
ÿ Conventionally insured___________________________________________________
ÿ Minimum premium______________________________________________________
ÿ Administrative Services Only (ASO)________________________________________
ÿ Other (please list) HIF__________________________________________________
ÿ New Health Carrier NJ Solutions - JHIF___________________
ÿ New Prescription Drug Carrier
ÿ New Dental Plan Carrier
ÿ Reason for termination from the SHBP/SEHBPX Cost savings to employees and taxpayers
In accordance with N.J.S.A. 18A:16-21 and 40A:10-25, you must file a copy of your new contract with the State Health Benefits Commission or School Employees’ Health Benefits Commission. Please submit a copy of the new contract with this completed resolution.
Mail Completed Resolution to: New Jersey Division of Pensions & Benefits Health Benefits Bureau
P.O. Box 299
Trenton, NJ 08625-0299