Employee Health Benefits Buyout Waiver Form
Employee Health Benefits Buyout Waiver Form
Full Name
*
First Name
Last Name
Employee ID
*
Department
*
Please Select
Human Resources
Finance
Operations
IT
Sales
Marketing
Other
Job Title
*
Work Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Declining Employer Health Benefits
*
Do you have alternative health coverage?
*
Yes
No
Date of Waiver Submission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Waiver
Should be Empty: