Waiver Of Group Health Insurance Coverage

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Harrisburg, PA 17177
WAIVER OF GROUP HEALTH
1-866-686-2242
INSURANCE COVERAGE
Capital BlueCross and its subsidiary,
Capital BlueCross and its subsidiary,
Capital Advantage Insurance Company
Capital Advantage Insurance Company
(collectively "Capital")
(collectively "Capital")
®
®
Independent Licensees of the Blue Cross and Blue Shield Association
Independent Licensees of the Blue Cross and Blue Shield Association
ALL SHADED AREAS MUST BE COMPLETED
1. APPLICANT INFORMATION
APPLICANT'S NAME
(LAST)
(FIRST)
(MI)
SOCIAL SECURITY NO.
SPOUSE'S NAME
(LAST)
(FIRST)
(MI)
SOCIAL SECURITY NO.
2. VALIDATION STATEMENT
I hereby certify that I have been given the opportunity to participate in the group health insurance plan provided by my employer through Capital. This plan has been explained to me and I decline to
participate in:
EMPLOYEE COVERAGE
SPOUSE COVERAGE
OTHER ELIGIBLE DEPENDENT COVERAGE
3. OTHER INSURANCE INFORMATION
Complete the following information for applicant and/or spouse and/or other eligible dependent(s) waiving coverage because they are currently covered for health care services with a Blue Cross and/or
Blue Shield Plan, an insurance company, an HMO, or other health care plan.
NAME OF CONTRACTHOLDER
NAME AND LOCATION (STATE) OF HEALTH CARE PLAN / INSURANCE CO.
POLICY / IDENTIFICATION NO.
4. WAIVER INFORMATION
5. COVERAGE BEING WAIVED
(CHECK ( ) COVERAGE BEING WAIVED)
NAME
(LAST)
(FIRST)
(MI)
RELATIONSHIP TO EMPLOYEE
SOCIAL SECURITY NO.
a. APPLICANT
b. SPOUSE
ELIGIBLE
c.
DEPENDENT
ELIGIBLE
d.
DEPENDENT
ELIGIBLE
e.
DEPENDENT
ELIGIBLE
f.
DEPENDENT
6. STATEMENT AUTHORIZATION
I understand that in the event that I decide to apply for this coverage at a later date, I and/or my spouse and/or any other eligible dependents, may be subject to certain waiting periods involving any preexisting conditions.
DATE
EMPLOYEE SIGNATURE
GROUP NO.
NAME OF GROUP
ORIGINAL — Capital
1st COPY — Applicant Copy
2nd COPY — Group Copy
C-69 (11/2002)
SEE REVERSE FOR INSTRUCTIONS

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