Health Insurance Waiver

Health Insurance Waiver
EMPLOYEE NAME (First & Last)*
Branch*
TODAYS DATE*

MonthDayYear
Date
JOB TITLE
I acknowledge I have been offered the opportunity to enroll myself and eligible family members in [Company Name]'s group health plan. I decline to enroll myself or the eligible family members listed below in the group health plan coverage:
Reason for Declining Coverage*

I have other Medical CoverageI do not wish to enroll myself or any eligible family members at this time
SIGNATURE*

Clear
EMPLOYEE NAME*
DATE*

MonthDayYear
Date
Should be Empty: