If you do not wish to participate in any coverage, please sign and date waiver, Section IV.
Employer's Name
Employer's Number
Participant's Name
I. EMPLOYEE INFORMATION
Group Name
Employee Social Security Number
Group Number
Div Number/Deductible
Last Name
First Name
Middle Initial
Physical Address
City
State
Zip
Date Employed
Effective Date
Emp. Date of Birth
Sex
Dependents First Name
Middle Initial
Sex
Date of Birth
Eff. Date Cov.
Full Time Student
School Attended
Social Security #
Disabled
II. COVERAGE INFORMATION
Health Coverage
Dental Coverage
Vision Coverage
Other
Amount of Life Ins.
Dependent Life
Amt. Weekly Income
Amt. Ltd
Other Coverage
Name of Spouse's Employer
Comments
III. OTHER INSURANCE
Are you or any other family member listed above eligible/covered by any other insurances?
IV. PAYROLL AUTHORIZATION
I hereby request my employer to arrange for the issuance of the insurance to which I am now entitled, or to which I may become entitled, under the terms of the group Policy or Policies issued to my employer, and I authorize my employer to make the proper deductions (if any) from my earnings as my contribution toward the cost of this insurance.
Date Signed
Signature of Employee
V. WAIVER OF EMPLOYEE GROUP COVERAGE
Employer
Group No.(S)
I have been given an opportunity to apply for group coverage offered by my employer, I understand the benefits available, and I decline: for
The reason for my declination is:
I understand that if I want to apply for this coverage at a later date it will be necessary to provide evidence of good health at my own expense and that coverage will then become effective only upon approval by the plan supervisor.