Small Employer Health Benefits Waiver Of Coverage Template printable pdf download

Small Employer Health Benefits Waiver Of Coverage Template

Small Employer Health Benefits

Waiver of Coverage

Group Policy Number_____________ Policyholder

Name______________________________

Employee Name (Last, First, MI) _______________________________________________

Social Security #_________________________

Marital Status: □ Single □ Married □ Widowed □ Divorced

Date of Employment__________

Date of Birth_______________

I was given the opportunity to enroll in this plan of group health benefits offered by my

employer and insured by CIGNA. I refused the following:

□ Employee

□ Employee, Spouse and Child(ren) coverage

□ Spouse Coverage

□ Child(ren) coverage

Reason for Refusal (Please check all appropriate boxes.)

□ Other group coverage sponsored by my employer

□ Other group coverage sponsored by my spouse's employer

□ Other group coverage sponsored by another organization

□ Other reasons (please explain)

Please provide name of carrier and policy number:___________________________________

I understand that if I later wish to enroll for any of the coverage(s) refused, I will be required to

submit an Enrollment Form

Signature of Employee____________________________________ Date________________

“Cigna” is a registered service mark and the “Tree of Life” logo is a service mark of Cigna Intellectual Property, Inc., licensed for use by

Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not

by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance

Company, Cigna Health Management, Inc., Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health

Corporation and Cigna Dental Health, Inc.

Small Employer Health Benefits Waiver Of Coverage Template