INSURANCE WAIVER FORM

INSURANCE WAIVER FORM
Complete this form if you are:

A newly eligible employee waiving coverage, or, A currently enrolled employee waiving coverage for yourself and/or your spouse/dependent(s
Employee Name print*
Eligible Spouse:
Eligible Dependent(s):
Eligible Dependent(s):
Eligible Dependent(s):
Eligible Dependent(s):
Eligible Dependent(s):
Waive Reason Codes:
1. Coverage does not meet my needs
2. Do not want to be insured
3. Participating in Domestic Partner's Plan
4. Participating in Parent's Plan
5. Plan to participate in State Exchange Plan
6. Participating in Spouse's Plan
7. Participating in State Exchange Plan
8. Too expensive
I elect to WAIVE “health” insurance coverage for Myself - Waive Reason Code?
I elect to WAIVE “health” insurance coverage for My Spouse - Waive Reason Code?
I elect to WAIVE “health” insurance coverage for My Dependents - Waive Reason Code?
I elect to WAIVE “vision” insurance coverage for Myself - Waive Reason Code?
I elect to WAIVE “vision” insurance coverage for My Spouse - Waive Reason Code?
I elect to WAIVE “vision” insurance coverage for My dependents - Waive Reason Code?
I elect to WAIVE “dental” insurance coverage for Myself - Waive Reason Code?
I elect to WAIVE “dental” insurance coverage for M Spouse - Waive Reason Code?
I elect to WAIVE “dental” insurance coverage for My Dependents - Waive Reason Code?
Employee Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: