DECLINATION OF MEDICAL COVERAGE

DECLINATION OF COVERAGE

TROOST CEMETERIES
This is to certify the available coverage has been explained to me. I have been given the opportunity to apply for the coverage offered to me and my eligible depedents and have voluntarily elected to decline the coverage as indicated below. If I desire to apply for coverage at a later date, I understand there may be a delay in the effective date of the coverage.
Employee Name*

First NameLast Name
Reason for declining HEALTH:*

Other Group Health CoverageOther Individual Health CoverageI am not enrolled in any health insurance plan, but do not want this coverage
Carrier:
MedicareMedicaid
Individual Carrier:
Other (explain):
Date

MonthDayYear
Date
Signature*

Clear
HR email
example@example.com
Should be Empty:

DECLINATION OF COVERAGE