Comprehensive Nursing Services, Inc. Group Insurance Waiver
Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
I am Waiving my oppurtinity to enroll in CNS 2017 Group Insurance
*
Please make a selection
Yes, I understand and will provide the needed documentation.
Will you or your dependents continue health coverage with another insurer?
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Yes
No
Other Health Insurer Name:
*
Who is covered?
*
Self
Spouse/Partner
All
Effective Date
*
Submit
Should be Empty: