Waiver Of Benefits

Waiver of Benefits

Employee Name:____________________________________
Employee ID No.:____________________________________
Employment Start Date: ______________________________

I, the aforementioned Employee, hereby verify and attest that I have been offered membership in the following medical insurance group plan through {Company}: {Insurance Company, Insurance Level, Monthly Cost, Benefits, etc.}.

I hereby acknowledge and attest that I have declined to join the medical insurance group plan listed above for the following reason:

• I am already on the following medical insurance plan: {Plan and ID}
• I am covered by my spouse's medical insurance plan: {Plan and ID}
• I receive benefits through Medicare or another government program: {Plan and ID}
• Other: {Specify}

I understand that by declining membership in the medical insurance group plan at this time, I will not have the option to enroll in the group until {date} if I choose to do so.

____________________________________
Signature

_________________________________
Date

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