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Waiver of Employee Group Insurance

Waiver of Employee Group Insurance

Please explain your reason(s) for
declining coverage under your Company's Group Plan

Company Name
 Account Number/Group Number
Employee Name
 Social Security Number
Date of Hire

e.g. 02/14/2000		 Date of Birth

e.g. 02/14/1970

REASON FOR WAIVER OF COVERAGE

You are required to state the reason(s) why you and/or your
eligible dependents have declined coverage under the Company's Group Plan.

Spouse's group health benefit plan or employer-sponsered plan

Spouse's employer:

Spouse's insurance carrier:

Membership Number:
Individual (non group) Health Benefit Plan (including Medicare, Medicaid, and Champus) Insurance carrier:
Another group health plan
offered through my employer		 Insurance carrier:
COBRA Continuation coverage My Current Employer:

My Previous Employer:
Medicare, Medicaid, or Champus through another employer  
Enrolled in another type of Insurance plan or arrangement Specify:
Declining my employer's group health benefit plan even though I currently have no other coverage  

I hereby certify that the medical benefits provided by my Employer have been explained to me; that I have been given an opportunity to apply for Plan coverage; and that I voluntarily decline to participate in the Plan due to the reason(s) stated above.

I understand that I am required by my Employer to complete and sign this statement. If this statement has been completed and if the reason for declining coverage is because of other health benefit coverage which is later lost, or exhausted in the case of COBRA coverage, I may enroll for coverage under this plan and the effective date will be the date the prior coverage was terminated or exhausted as long as I enroll within 31 days of the date of termination or exhaustion. If this statement has not been completed and if I do not enroll within the 31 day timeframe, then I understand that I must wait until the next open enrollment period to enroll.

Employee Signature:
Date:  e.g. 02/14/2000

Submission of this form will allow Benefit Design Group, LLC to process the information contained in this document. The Employer agrees to maintain a signed copy of this document. Benefit Design Group, LLC, reserves the right to request a copy of the signed document at any time from the Employer.




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