Employee Health Insurance Waiver Form
Employee Health Insurance Waiver Form
Please provide all the necessary information below to complete this form.
Name
Employee ID
Department
Job Title
Date of Hire
Waiver of Health Insurance Coverage
I, the undersigned, hereby acknowledge that I have been offered health insurance benefits by [Your Company Name] but am choosing to decline this coverage at this time. By signing this waiver, I confirm the following:
-
I understand that by waiving this health insurance coverage, I will not receive any health insurance benefits provided by [Your Company Name].
-
I am aware that I will not be able to enroll in the company’s health insurance plan until the next open enrollment period, or until I experience a qualifying life event that allows for special enrollment.
-
I affirm that I am waiving coverage voluntarily and without coercion.
-
I understand that any medical expenses I incur will not be covered by [Your Company Name]'s health insurance plan.
Date:
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