Employee Benefits Waiver Form
Employee Benefits Waiver Form
Please fill out this form to confirm your decision to waive certain employee benefits.
Name
Role/Position
Department
Date of Hire
Waived Benefit(s)
Select all that apply:
-
Health Insurance
-
Dental Insurance
-
Vision Insurance
-
Short-Term Disability Insurance
-
Long-Term Disability Insurance
-
401(k) Retirement Plan
-
Flexible Spending Account (FSA)
-
Health Savings Account (HSA)
Reason for Waiver
Please provide a brief explanation for waiving the benefits above:
Acknowledgment
By signing below, I acknowledge that my decision to waive certain benefits is voluntary and that I accept any resulting limitations. By waiving these benefits, I understand that I am forfeiting any associated coverage, compensation, or contributions.
Name:
Date:
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