Health Insurance Waiver
I. Introduction
This Health Insurance Waiver Agreement ("Agreement") is entered into by and between [EMPLOYEE'S FULL NAME] ("Employee") and [YOUR COMPANY NAME] ("Company"). This document confirms the Employee's voluntary decision to waive participation in the Company-provided health insurance plan.
II. Voluntary Participation
The Employee acknowledges and agrees that participation in the health insurance plan provided by [YOUR COMPANY NAME] is entirely voluntary, and the Employee has decided not to participate at this time. The Employee confirms they have been informed about the benefits and risks associated with opting out of this plan.
III. Alternative Coverage Declaration
[EMPLOYEE'S FULL NAME] confirms that they have secured alternative health insurance coverage effective as of the date below. Details of the alternative health insurance provider must be furnished upon request of [YOUR COMPANY NAME].
IV. Release and Waiver of Claims
By signing this Agreement, [EMPLOYEE'S FULL NAME] releases and forever discharges [YOUR COMPANY NAME], its affiliates, successors, and assigns from any claims, demands, or causes of action that are in any way related to [EMPLOYEE'S FULL NAME]'s decision to opt out of the Company-provided health insurance plan.
V. Reinstatement of Benefits
[EMPLOYEE'S FULL NAME] understands that reinstatement into the Company's health insurance plan is subject to the terms and conditions set by [YOUR COMPANY NAME] and may only occur during designated enrollment periods or following a qualifying life event, pursuant to the plan's rules.
VI. Legal Acknowledgment
[EMPLOYEE'S FULL NAME] expressly agrees and understands that this waiver complies with applicable laws and fulfills the requirements stipulated by regulatory authorities. This waiver does not remove the obligations of [YOUR COMPANY NAME] to offer insurance where legally required.
VII. Signature
By signing this document, [EMPLOYEE'S FULL NAME] confirms they have read, understood, and voluntarily agree to the terms outlined herein. The Employee acknowledges they have had the opportunity to ask questions about this waiver and consult with an advisor of their choice.
Employee Signature:
Print Name: [EMPLOYEE'S FULL NAME]
[Date]
Representative's Signature:
Printed Name: [YOUR NAME]
[Date]
VIII. Company Acknowledgment
This document was prepared by [YOUR NAME], officially representing [YOUR COMPANY NAME]. For any inquiries regarding this Agreement, please contact us via the information below:
Email: [YOUR COMPANY EMAIL]
Phone: [YOUR COMPANY NUMBER]
Address: [YOUR COMPANY ADDRESS]
Waiver Templates @ Template.net
