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:

            1. I understand that by waiving this health insurance coverage, I will not receive any health insurance benefits provided by [Your Company Name].

            2. 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.

            3. I affirm that I am waiving coverage voluntarily and without coercion.

            4. 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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