Date: _______________________________________
Employee name: ______________________________
Department: __________________________________
Position: _____________________________________
I acknowledge I have been offered the opportunity to enroll myself and eligible family members in [Company Name]'s group health plan.
I decline to enroll myself or the eligible family members listed below in the group health plan coverage:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
□ I have other medical coverage provided by:
Insurance company name: ________________________
Policy/group number: _____________________________
Through (Employer Name): ________________________
□ I do not wish to enroll myself at this time.
□ I do not wish to enroll any eligible family member at this time.
Signature: ________________________________ Date: _________________
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