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MEDICAL/DENTAL WAIVER
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1
Fontaine Weatherproofing Inc. offers medical and dental insurance. Which insurance are you declining?
A) MEDICAL & DENTAL
B) MEDICAL ONLY
C) DENTAL ONLY
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2
What's your FIRST name?
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3
What's your LAST name?
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4
What's your Social Security #
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5
I have been offered coverage by Fontaine Weatherproofing Inc., but at this time, I wish to decline MEDICAL coverage for:
MYSELF AND DEPENDENTS
SPOUSE
DOMESTIC PARTNER
CHILD(REN)
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6
I have been offered coverage by Fontaine Weatherproofing inc., but at this time, I wish to decline DENTAL coverage for:
MYSELF AND DEPENDENTS
SPOUSE
DOMESTIC PARTNER
CHILD(REN)
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7
Today's Date
-
Date
Month
Day
Year
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8
Signature
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