Waiver Of Coverage - Mercycare

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WAIVER FORM
EMPLOYEE INFORMATION
Employee Last Name
First Name
Middle Initial
Social Security Number _
Birthday (Month/Date/Year)
Sex
Home Address
County
City
State
Zip Code
Employee’s Home Telephone
Employer’s Name
Employer Telephone
CURRENT MARITAL STATUS (CHECK ONE)
Single
Married
Widowed
Divorced
Separated
OTHER HEALTH INSURANCE INFORMATION/COORDINATION OF BENEFITS
Are you or any of your dependents eligible for Medicare Benefits?
No
Yes
If yes, Name
Do you or any dependents have other group medical coverage in addition to this plan?
No
Yes If yes,
indicate carrier
Did you have prior medical coverage?
No
Yes If yes, indicate carrier
Did dependent (s) have prior medical coverage?
No
Yes
If yes, indicate dependent (s)
Carrier
Phone #
Policy #
Effective Date
Term Date
WAIVER OF COVERAGE
I understand that I am eligible to apply for group health insurance through my employer. I do NOT want, and hereby
waive, group health insurance for (check box that applies) :
Waiving for myself
Waiving for my spouse
Waiving for my dependent child (ren)
Waiving for
myself and family
I am waiving group health insurance because (check all that apply):
I, the employee, am covered or will be covered under another plan that is not sponsored by my
employer. If currently covered, please attach a copy of your identification card for that plan.
My spouse is covered or will be covered under another plan that is not sponsored by this employer. If
currently covered, please attach a copy of your spouse’s identification card for that plan.
mcwavjan2014
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