CPS Health & Dental Waiver form

Employee Name:

First NameLast Name
Eligible Spouse/Dependent(s):
I elect to:

WAIVE Tufts "HEALTH" insurance coverage
If you chose to WAIVE Tufts "HEALTH" insurance coverage for (check all that apply):

MyselfMy SpouseMy Dependents
I elect to:

WAIVE Guardian "DENTAL" insurance coverage
If you chose to WAIVE Guardian "DENTAL" insurance coverage for (check all that apply):

MyselfMy SpouseMy Dependents
I elect to

WAIVE VSP vision insurance coverage for (check all that apply):
If you chose to WAIVE VSP vision insurance coverage for (check all that apply):

MyselfMy SpouseMy Dependents
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: