Free Employee Benefits Waiver Form Template

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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