Waiver Form

    • Employee NameSSNDate of BirthFull AddressDate of HireSalaryBeneficiary Name & Relationship 
    • Disclaimer:

      I acknowledge the following employees have been given the opportunity to apply for this medical coverage. However, they are choosing to not enroll. By declining this group health coverage they acknowledge that themselves and their dependents may have to wait until the plan’s next anniversary date to enroll for group health coverage.