Benefits Waiver and Decline Form
Employee Information
Full Name
Employee ID
Department
Date
Benefits Waived / Declined
Medical Insurance
Dental Insurance
Vision Insurance
Life Insurance
Other
If Other, please specify:
Reason for Waiving / Declining
Employee Acknowledgment
By signing below, I acknowledge that I have been offered the above benefits by my employer and that I am voluntarily waiving/declining the indicated coverages.
Employee Signature
Date