Employee Health Insurance Waiver Form
Please provide all the necessary information below to complete this form.
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:
Employee Waiver Templates @ Template.net
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