Insurance Waiver Form
Name
First Name Last Name
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date of Birth
Month Day Year
Date
Declaration of Waiver
I understand that I have been offered a group health insurance by the Company including my eligible dependent(s), with an insurance service provider. I am electing not to enroll myself, or my dependents at this period.
I understand that should I or including my dependent(s) desire to to obtain a group health insurance in the future, it shall be under the condition of availability of the group insurance policy that they offer to employees.
Under any circumstance, I shall not hold the Company liable for any financial matters incurred which may relate to this waiver.
I hereby release, remise and discharge from any claims and liabilities whatsoever without limitations that I might have against the Company and its owners due to any circumstance which might occur and is extended by the group insurance policy.
And I make this release on behalf of myself, my heirs, executors, assigns and administrators.
By signing this waiver I fully agree that the company has taken all reasonable practicable action to protect my health and safety
Employee Signature
Clear
Date Signed
Month Day Year
Date
Should be Empty:

Insurance Waiver Form

Declaration of Waiver