You must complete this form if you are declining enrollment in the (COMPANY NAME) medical program.
Note:

· If you are declining enrollment for yourself and dependents because of other health insurance coverage, you may, in the future, be able to enroll in this plan, provided that you request enrollment within 30 days after your other coverage ends.

· If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

· The plan is not required to offer enrollment to “late enrollees.”

Important: Lack of “other coverage” does not create any responsibility for (COMPANY NAME).
Employee Initials

___ I decline MEDICAL coverage even though I do not have other medical coverage.
___ I decline MEDICAL coverage for myself.
___ I decline MEDICAL coverage for myself and my dependents.
___ I decline MEDICAL coverage for my dependent(s).
___ I decline MEDICAL coverage because I am currently covered under another plan. A copy of my current medical card is attached.*

*OTHER PLAN:
Name of Group Policyholder:
Name of Insurance Carrier:


Employee Name: (Please Print)

Last Name, First Name , Middle Name


Employee Signature :
Social Security Number :
Date:


Employer Name: (COMPANY NAME)

Witness Signature:
Date:



Copy: Employee Personnel File