Employee Insurance Waiver Form

Employee Insurance Waiver Form

Please provide all the necessary information below.

Company Name

    Employee Name

      Employee ID

        Date of Employment

          Position/Department

            Reason

              • I am covered by an alternative health insurance plan.

              • I prefer not to participate in the company’s insurance plan at this time.

              Acknowledgment of Waiver

              I hereby acknowledge that I have been offered insurance coverage by [Your Company Name] as part of the employee benefits package. I understand that by signing this waiver, I am choosing to decline this insurance coverage.

              Name:

              Date:

              Employee Waiver Templates @ Template.net

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