Free Health Insurance Waiver Letter Template
HEALTH INSURANCE WAIVER LETTER
August 16, 2054
John Doe
456 Elm Street
Springfield, CA 90876
Dear John Doe,
I am writing to confirm receipt of your request to waive the health insurance coverage offered by [Your Company Name]. As of September 1, 2054, you have opted out of participating in the company's health insurance plan.
By signing this waiver, you acknowledge the following:
You understand that by opting out of the company’s health insurance plan, you will not be eligible to receive any of the health insurance benefits provided by [Your Company Name]. This includes medical, dental, vision, and prescription coverage. You also acknowledge that you are responsible for obtaining health insurance coverage through other means, such as a spouse’s plan or a private policy.
You confirm that you have made this decision voluntarily and with a full understanding of the implications. You have had the opportunity to ask questions and receive information regarding the health insurance options available to you. You understand that opting out of the company’s plan does not qualify you for any reimbursement or compensation for health-related expenses incurred during this period.
You acknowledge that you will not be covered under the company’s health insurance plan, including any health-related benefits, during the period of this waiver. This waiver remains in effect until you provide written notice to [Your Company Name] of your desire to enroll in the health insurance plan again. You understand that if you wish to re-enroll, you may be subject to open enrollment periods or other conditions as specified in the company’s health benefits policy.
Please sign below to indicate your acknowledgment and acceptance of the terms outlined above.
Sincerely,
[Your Name]
HR Manager
Employee Acknowledgment:
I, John Doe, acknowledge that I have read and understood the terms of this Health Insurance Waiver and agree to opt out of the health insurance coverage provided by [Your Company Name].
[Your Name]
Please return this signed letter to ABC Corporation by August 30, 2054.
Thank you for your attention to this matter.
Best regards,
[Your Name]
HR Manager
