Employee Benefits Refusal Form
Employee Benefits Refusal Form — record the benefits you are declining and confirm your decision.
Employee Name
*
First Name
Last Name
Work Email
*
example@example.com
Department
*
Which benefits are you declining?
*
Medical insurance
Dental insurance
Vision insurance
Life insurance
Retirement plan
Other
Requested Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for declining (optional)
Employee Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Form
Submit Form
Should be Empty: