Form Bcbs 16628 - Enrollment Form (Page 2 of 2) in pdf

Form Bcbs 16628 - Enrollment Form Page 2

DECLINATION

Employee Name: _____________________________________ Social Security #: ______________________

Check which coverage declined.

Medical

Dental

Employee ID#: ________________________

Occupation: __________________________________________ Birth Date: ___________________________

Address: __________________________________________________________________________________

City: ________________________________________________ State: _________ Zip: _________________

Marital Status: ___________________________

Sex:

Hire Date: _____________________

NOTE: You must complete this form if you are waiving (declining) insurance coverage available to you through

your Employer.

This is to certify that I have been given the opportunity to apply for group coverage available to me and my

dependents pursuant to state law through my Employer. I proclaim that I was not pressured or forced by my

Employer into waiving (declining) the above noted coverage. I understand that in the event that I should decide

to apply for such coverage, hereafter, that such subsequent applications shall be subject to the applicable terms

and conditions of the Master Group Contract.

Date: _______________________ Employee Signature: ___________________________________________

BCBS 16628

Rev. 1/09

Form Bcbs 16628 - Enrollment Form Page 2